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STATE OF CALIFORN16 WATER RESOURCES CONTROOARD " : ;• FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANKTANK PERMIT APPLICATION INFORMATION �jOMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C 03E() ONE ITEM ❑2INTERIM PERMIT ❑ 4 AMENDED PERMIT E] 6 TEMPORARY TANK CLOSURE E]8 TANK REM D Q FACILITY/SITE NAME WHERE TANK IS INSTALLED: Z70S-Tg FARM TANK-YES O •( 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK IU N D. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: O O a �^ C II. TANK CONTENTS IF(A.T),IS MARKED,COMPLETE ITEM C.IF(Al),IS NOT MARKED,COMPLETE ITEM D. V A. ❑ 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ I PRODUCT E]4 GASAHOL Lj 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ BO 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 A C.A.S.N C.A.S.C III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,B O A TYPE OF I-I I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ I STEEL/MYON ❑2 STAINLESSSTEEL ❑ 3 FIBERGUSS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE 6 POLYVINYLCHLORIDE ❑ T ALUMINUM ❑ B IOD%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER ❑ C. INTERIOR 1 RUBBER UNED ❑2 ALKYO UNING 3 EPDXY LINING ❑ 4 PHENOLICLINING LINING ❑ 5 GLASS LINING fi UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑ 3 VINYLWHAP E] 4 FIBERGLASSREINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 0 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 I SUCTION A U 2 PRESSURE A U 3 GHAVIIY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FHP A U 8 100%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,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VAUOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WAT ER MONITORING WELLS P S 8 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE ESTIMATED DATE LAST USED(MO/YR) �I 2. ESTIMATEDOUANTITYOF -- 3.WAS TANK FILLED WITH SUBS]ANCE 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. APPLICAN I'S NAME(PHINT ED 8 SIGNATURE) DATE I LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID N ® LL I I 111 11 r7l3l �l I CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NA PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK If PERMIT AMOUNT SURCHARG AMT. FEE CODE RECEIPTI IOIIM B(8-29-m) THIS FORM MUST BE ACCOMP R:D BY A FACILITY/SITE APPLICATION, FORM •A',UNLESS A CURRENT FORMA' MAS BEEN FILEDD DATA PROCESSING COPY