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STATE OF CALIFORN* WATER RESOURCES CONT BOARD FORM B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I 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 ❑8 TANK REMOVED1� FACILITY/SITE NAME WHERE TANK IS INSTALLED: EIna anae4— FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPE IFY IC A. OWNERS TANK ID# c"e B. MANUFACTURED BY: WK C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: /0" ,900 11. TANKj;p1fTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. tV A 1 OTO EHICLE FUEL ❑ 2 PETROLEUM R. C. ❑ 1 UNLEADED ❑2 LEADED 3 DIESEL A ❑ 3 CHEMICAL PRODUCT OIL PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUSEMPTY ❑ 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.# ;T _ C.A.S.#: im XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B,C,&D A. TYPE OF ❑ I DOUBLEWALLED F-13 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM I! `SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEELPRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL GLAD WIFIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM" ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER UNED ❑2 ALKYD LINING F-13 EPDXY LINING ❑4 PHENOLIC UNING C. INTERIOR LINING 5 GLASS LINING 6 UNLINED 95 UNKNOWN ❑ ❑ ❑ISUNING MATERIAL COMPATIBLEWITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENEWRAP 2 TAR OR ASPHALT ❑3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC 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 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A Q95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD WEEP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AOU 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 S 1 VISUAL CHECK ©S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 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(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH Z N A/� SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E]YES ❑ 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 B SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGFACILITY ID p APPROVED BY NAM PHONE#WITH AREA CODE S ENCY �e j - PERMIT NUMBER PERMIT APPROVAL DA PERMIT EXPIRATION DATE i CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: 1^ FORM B(3 7 se) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CUHRENT FORMA' HAS BEEN FILED �'J1