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STATE OF CALIFORNr WATER RESOURCES CONTRC 30ARD FORM B': UNDERGROUND STORAGE TANK PRMRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE F216ANK REMOVED Q FACILITY/SITE NAME WHERE TANK IS INSTALLED: qLjqL4N FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 10 A. OWNERS TA NK ID# �((— B. MANUFACTURED BY: JK C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: W II. TANK CO TENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COM TE ITEM D. Ln A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. UNLEADED ❑2 LEADED ❑3 DIESEL W ❑ 3 CHEMICAL PRODUCT ❑ 4 OILRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&CAS,It C.A.S.#'. All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,S.C.8 D A TYPE OF ❑ 1 DOUBLE WALLED 3 SINGLE WALLED WITH ERTERIOR LINER ❑ 95 UNKNOWN SYSTEM [j�151NGIEWALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ B 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR F—] I RUBBER UNED ❑2 ALKYD LINING F—] 3 EPDXY LINING 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING (❑.B'UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION NE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE AIFAS U EGROND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTIONASINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER AV STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S_ 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P PRECISION TESTING P S ] PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MOND) 2. ESTIMATED QUANTITY OF 3,WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL' ❑ YES E:] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FACI44 LITY IDM AP R V O BY NAM PHONE#WITH AREA CODE CL I F PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM a(3a-88) THIS FORM MUST BE ACCOMPAN 'A FACILITY/SITE APPLICATION, FORM 'A',UNLESS RENT FORM'R HAS BEEN FILED DATA PROCESSING COPY