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FORM 'B': UNDERGAND STORAGE TANNFORMARON and/or PERMITION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑� /3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 TANK REMOVED ONE ITEM ❑2 INTERIM PERMIT ra 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 PERMANENTLY CLOSED TANK FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARMTANK-YES❑ NO I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK I.D.# /—D B. MANUFACTURED BY: C YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM B.IF AA.1),IS NOT MARKED,COMPLETE ITEM C. A. I MOTOR VEHICLE FUEL ❑2 OTHER PETROLEUM PRODUCT B. 211 UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 WASTE OIL ❑ 4 GASAHOL 5 JET FUEL 6 AVIATION GAS ❑5 OTHER HAZARDOUS WASTE ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM C,SELOM C. IF NOT MOTOR VEHICLE FUEL,EN[ER NAME OF C.A.S.# HAZARDOUS SUBSTANCE STORED&C.A.S.N 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,D A.TfPEOF I DOUBLE WALLFD ❑2 SINGLE WALLED ❑3 SINGLEWAILEDWITHE%TEn:O;LINER SYSTEM ❑ 4 SECONDARY CONTAINMENT ❑95 UNKNOWN ❑99 OTHER — ❑ ( STEEL/IRON ❑ 2 STAINLESS STEEL ❑3 fIBERGLASS d STEEL CLAOW/FIBERGLASS FE'.NF09CED PLASTIC S.TANK ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑8 100%METHANOL COMPATIBLE PP MATERIAL ❑ 9 BRONZE ❑ IO GALVANIZED STEEL ❑95 UNKNOWN 99 OTHER ❑ I RUBBER LINED ❑ LKYD LINING ❑3 EPDXY UNING ❑ 4 PHENOLIC LINING C. INTERIOR ❑5 GIASSUNING �6 UNLINED ❑ 91 NONE ❑95 UNKNOWN LINING ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROCTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A®2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) /(5>4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY 9 1 VISUAL CHECK I P S 2 INVENTORY RECONCILIATION P S 4 VADOSE WELLS {'�S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 5 6 PRECISION TESTIN S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER P R VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF 3,WAS TANK FILLED WITH SUBSTANCE REMAINING INERT MATERIAL? ❑YES 0 N In GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLI TS NAME(PRINTED d SIGNATURE) A9//�7/v4.•G �DATE �aTfi�L S LOCAL AGENCY USE UNLT 5irz 1(ill4ic.rTL COUNTY M JURISDICTION M AGENCY X FACILITY ID M TANK ID R CURRENT LOCAL AGENCY 10 Y PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE FEE CODE CHECK# AMOUNT SURCHARGE AMT. RECEIPT BY: FORM B(1-8a) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION,FORM W,UNLESS A CURRENT FORM 'A' HAS BEEN FILED