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S7.47E OF CALPFORNL , WATER RESOURCES CONTRC"30ARD FORM `B': UNDERGROUND STORAGE TALK PRO`e;RAM �� TANK PERMIT APPLICATION INFORMATION o- NK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. � z IG MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION W;-TANK PE NENTLY CLVNOrlo ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE REMOVEDFACILITY/SITE NAME WHERE TANK IS INSTALLED: FARMTANK-YES❑ Cr►? 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 4% A. OWNERS TANK IDN B. MANUFACTURED BY: A C. YEAR INSTALLED L4 A, D. TANK CAPACITY IN GALLONS: SQ, coo II. TANK CONTENTS IF(a1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM O. A. ❑ 1 MOTOR VEHICLE L ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT 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 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,EN R NAME OF HAZARDOUS SUBSTANCE STORED A.S.# C.A.S.k: 111. TANK CONSTRUCTION MAR ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑1 DOUBLE WALLED 3SINGLEWALLED NTH EXTERIOR LINER ❑95 UNKNOWN SYSTEU ❑2 SINGLE WALLED ❑ ONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑2 Si SS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE E:]6 POLYVI LCHLORIDE ❑7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL El9 BRONZE ❑ 10 GALVANIZ STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOUC UNING G INTERIOR N NRI R F-15 GLASS UNING ❑6 UNLINED ❑95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION [:]5 CATHODIC PROTECTION ❑91 NONE RUNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UN ERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A 3 GRAVITY 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 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 OLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.HATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 EEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 0 ER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDA ,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 LECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 NKNOWN P S 99 OTHER 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 IN 4oms INERT MATERIAL? F-1YES F-1NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST F MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY S JURISDICTION N AGENCY S FACILITY IDS TANK ID S [m I I I I 1 � o 0 F1 1310161o _Fr) I a I CURRE LOCAL AGENCY FACILITY ID fi AP70-110 D BY NAME tiQ PHONE N WITH AREA CODE I PERMIT UMBER PERMIT APPROVAL DATE RLI EXPIRATION DATE CHECK 1 PERMIT AMOUNT SURCHARGE ALIT. FEE CODE RECEIPT• BY: FORM B(6-29-88) THIS FORM DUST BE ACCOk1PANIED BY A FACILITY/SITE APPLICATION, FORM`A',UNLESS RRENT FORWK HAS BEEN FILED ''�, DATA PROCESSING COPY