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STATE OF CALIFORNi % WATER RESOURCES CONTRr' BOARD FORM 'B': UNMERGROUND STORAGE TANK PROSRAM r TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING 1 MATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT F-15' 3 RENEWAL PERMIT CHANGE OF INFORMATION F-] 7 PERMANENTLY CLOSED TANK 1C ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 70lrareaAde FARM TANK-YES❑ NO CA. I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY (C A. OWNERS TANK O# *1- Z B. MANUFACTURED BY: C C. YEAR INSTALLED 'C1 D. TANK CAPACITY IN GALLONS: QeRd n0. II. TANK C TENTS IF(At),IS MARKED,COMPLETE REM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. V / A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. UNLEADED ❑ 2 LEADED ❑ 3 DIESEL F-13 CHEMICAL PRODUCT ❑ B.4 OIL 1 PRODUCT 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&C.A.S.N CAS.W �✓�( /99 III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,&D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM Y7ALUD ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER /IRON ❑2 STAINLESS STEEL ❑ 3 RBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 100%MUKV40LCOMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ 1RRUUNEED ❑2 ALKYDUNING F] 3 EPDXY UNING F-14 PHENOLIC UNING G LN LINING 5 MG ❑6 UNUNFD ❑%UNKNOWN _ [:] IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑YJ`' ❑99 OTHER D. CORROSION ❑ I POLYETHENE WRAP TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED RASRC PROTECTION ❑ 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 I SUCTION A(U)2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALLED A V 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 7 5 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD WIMP A U 8 10 p%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A(�U>5 UNKNOWN A U 99 OTHER /VY. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. / 1 P S 1 VISUAL CHECK P 4 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 9 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 11 I+L✓i�/'1} P S PRECISION TESTING P 9 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S W OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST U ED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO 'L t' GALLONS THIS FORM HAS hEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION � AGE /^: FACILITY IDN TANK ID# CURRENT LOCAL AGEP7 FACILITY ID i `-'� APPROVED BY NAME PHONE i WITH AN CODE Q V 7 —0 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DfE CHECK N PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT♦ BY: FORM B(6-29-88) THIS FORM MUST BE ACCO MPAhI EY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A c.,fPEM FORMA' HAS BEEN FILED ,2-/ 1� DATA PROCESSING COPY