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STATE OF CALIFORNI WATER RESOURCES CONTRC OARD FORM 'B': UNDEM6ROUND STORAGE TANK PRO- RAM �� TANK TANK PERMIT APPLICATION INFORMATION (a '.�o COMPLETE A SEPARATE FORM WITH THE FOLLOWIN FORMATION FOR EACH TANK. -_- Z i C7 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO NK ONE ITEM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT [-] 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED /y FACILITY/SITE NAME WHERE TANK IS INSTALLED: JS_J/-� 1 15111 :& FARM TANK-YES NO ❑ (� f I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: W C. YEAR INSTALLED ilkD. TANK CAPACITY IN GALLONS 4:�- II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. ❑ 1 UNLEADED E]2 LEADED E]3 DIESEL 3 CHEMICAL 4 OIL FUEL ❑5 HAZARDOUS PRODUCT 80 EMPTY 95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑ 99JOTHER(DESCRIBE❑IN TEM D?ELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: 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 ❑2 SINGLE WALLED 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEUIRON ❑25TAINLESS STEEL ❑3 FIBER ❑4 STEEL CUD W/FIBERGLAS$REINFORCED PLASTIC B.TANK F-15 CONCRETE ❑6 POLYVINYLCHLORIDE 7 MINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY LINING 4 P L LINING 5 GLASS LINING 6 UNLINED 95 IC LINING C.INTERIOR UNKNOWN ❑ ❑ ❑IS LINING MATERIAL COMPATIBLE WITH IOD%METHANOL? ❑YES NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TARORASPHALT ❑S>IK<WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE LV95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U9, UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 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 ;g:= A U 7 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 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 P 3 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S S, PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 5 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 SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN 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# AGENCY# FACILITY ID# TANK ID# Nm = = 1001011 -7131D O LL / CURRENT LOCALAOENCY FACILITY ID N APPROVED BY NAME PHONE M WITH AREA CODE PERMITNUMBER �(�J)35 PERMIT APPROVAL DATE PERMIT EXPIRATION DATE Vtl 6-i2-P9 CHECK# PERMIT AMOUNT SURCHARGE ANT. FEE CODE I RECEIPT# BY:, FORM B(6-29-B8) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM'W HAS BEEN FILED DATA PROCESSING COPY