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STATE OF CALIFORNik WATER RESOURCES CONTR*OARD FORM 'B': UNDffRGROUND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 'TANK MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM F-12 INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑ 6 TEMPORARY TANK CLOSURE�NK REMOVED O 1- - R' oYA FARM TANK NO FACILITY/SITE NAME WHERE TANK IS INSTALLED: S 'T��'� _ I. TANK DESCRIPTION COMPLETE ALL ITEMS -IF UNKNOWN -SO SPECIFY B. MANUFACTURED BY: A. OWNERS TANK ID # C YEAR INSTALLED I Z'Ic3� TANK CONTENTS IF (A.1) IS MARKED, COMPLETE ITEM C. IF IV. LTM D. TANK CAPACITY IN GALLONS IS NOT c. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT F-1 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF HAZARDOUS SUBSTANCE STORED a C.A.S. # vu, anVA a An COMPLETE ITEM D. 1 UNLEADED ❑ 2 LEADED 4 GASAHOL ❑ 5 JET FUEL [_j 6 AVIATION GAS F-17 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW) C.A.S. #: ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 4 STEEL DEAD W/FIBERGLASS REINFORCED PLASTIC ❑ 8100% METHANOL COMPATIBLE FRP ❑ 99 OTHER ❑ 4 PHENOUC LINING ❑ 95 UNKNOWN �THER ❑ 4 FIBERGLASS REINFORCED PLASTIC ❑ 99 OTHER I'IYIIWa 1PIrwmm�o .n,. -�. .......__..__. A SYSTEM TYPE A U 1 SUCTION A B CONSTRUCTION A U 1 SINGLEWALLED A A U 1 STEEL/IRON A C. MATERIAL A U 5 ALUMINUM A A U 9 GALVANIZED STEEL A _. _ U 2 PRESSURE U 2 DOUBLEWALLED U 2 STAINLESSSTEEL U.6 CONCRETE U 5 UNKNOWN A A A A A U 3 GRAVITY A U 91 NONE U 3 LINED TRENCH A U 91 NONE U 3 POLYVINYL CHLORIDE (PVC) A U U 7 STEELCLAD W/FRP A U U '99 OTHER LJ ' DOUBLE WALLED ❑ 3 SINGLEWALLED WITH EXTERIOR LINER A TYPE OF SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 GLASS B. TANK ❑ 5 CONCRETE E]6 POLYVINYLCHLORIDE ALUFIBEMINUM ❑ 7 ALUMINUM MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN SURCHARGE AMT. ❑ 1 RUBBEBUNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING C. INTERIOR ❑ 5 GLASS LINING UNUNED LINING ❑ IS LINING MATERIAL COMPATIBLEWITy+fQ096 METHANOL? ❑ YES ❑, NO D. CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2TAR OR ASPHALT 3VINYL WRAP PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN COMPLETE ITEM D. 1 UNLEADED ❑ 2 LEADED 4 GASAHOL ❑ 5 JET FUEL [_j 6 AVIATION GAS F-17 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW) C.A.S. #: ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 4 STEEL DEAD W/FIBERGLASS REINFORCED PLASTIC ❑ 8100% METHANOL COMPATIBLE FRP ❑ 99 OTHER ❑ 4 PHENOUC LINING ❑ 95 UNKNOWN �THER ❑ 4 FIBERGLASS REINFORCED PLASTIC ❑ 99 OTHER I'IYIIWa 1PIrwmm�o .n,. -�. .......__..__. A SYSTEM TYPE A U 1 SUCTION A B CONSTRUCTION A U 1 SINGLEWALLED A A U 1 STEEL/IRON A C. MATERIAL A U 5 ALUMINUM A A U 9 GALVANIZED STEEL A _. _ U 2 PRESSURE U 2 DOUBLEWALLED U 2 STAINLESSSTEEL U.6 CONCRETE U 5 UNKNOWN A A A A A U 3 GRAVITY A U 91 NONE U 3 LINED TRENCH A U 91 NONE U 3 POLYVINYL CHLORIDE (PVC) A U U 7 STEELCLAD W/FRP A U U '99 OTHER A 9 UNKNOWN A U 99 OTHER A U 5 UNKNOWN A U 99 OTHER d FIBERGLASS PIPE A U 91 NONE 8 100% METHANOL COMPA71BLEFRP AGENCY # :v.. R!MARY na c FnR RFCONDARY. A PRIMARY LEAR Ue l cw lvn a.a. cm m.... • -- - LEAK UC I rCIIvPd a. a. A -v. CIRU� ..,, ••••••••...._.._ _ P S 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS P S 95 UNKNOWN P 8 99 OTHER P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE VI. INFORMATION ON TANK PERMANENTLY CLOSED IN FLAL:e 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH 1, ESTIMATED DATE LAST USED (MO/YR) SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑ YES ❑ NO THIS FC RM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS THUL ANL) UL DATE APPLICANT'S NAME (PRINTED & SIGNATURE) — 3RECT. 0 Pa 0 N LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # AGENCY # FACILITY ID # plbia= TANK ID # ot�a I LOCAL AGENCY FACILITY ID # APPROVEDD7BY NAME � I � I � PHONE k WITH AREA CODE 1 1G LCJ Z l.�l•/,j UMBER FCHECK# PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT # BY: _ - __ ------------ . UT PnaU'A' NAR RFEN FILED .A. ,UL cac RE FORMB(6-29-86) THIS FORM MUST BE ACCOMPANI'A PACIUI vn ae A"LIa Kn.... vR, .....�,....___-.. __._.__ _