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STATE OF CALIFORNIA, WATER RESOURCES CONTROL ti.ARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM #90557B a� TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EAC"TANK. MARK ONLY ❑ 1 NEW PERMIT 143 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM El INTERIM PERMIT F-18 d AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: ROILS Personalized CheVTOII SCTVICC FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID N WC5718CS. MANUFACTURED BY: unknown C. YEAR INSTALLED 1969 1 D. TANK CAPACITY IN GALLONS: 5,000 gallons 11. TANK CONTENTS IF(At),IS MARKED,COMPLETE REM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ® 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ® 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑A OIL ® 1 PRODUCT ❑A GASAHOL ❑S_.ET FUEL .,....,.❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑%UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99?Myffit IN OfM,0 BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 C.A.S.N {i r,)YT V�,I@YA�f[VnJM f,\l CIA 19 Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,SD PERIM lT/SEi3VIC;_.. A TYPE OF ❑I D(NNLEWAUBI ❑3 SINGLE WALLED WITH 9MRION LINER ❑95 UNKNOWN sYSTEM ❑X 2 SINGLE WALLED ❑1 SECONDAINCONTAN MENT ❑99 OTHER ❑1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑X STEEL CUD WIFIBERGLASS REINFORCED PLASTIC L TAN ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 tOD%METHANOL COMPATIBLE FRP MATEMAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑1 PHENOLIC LINING C.INTERIOR5 GLASS UNING X❑6 MARLED NIOIOWN LINING ❑ ❑95 U ❑IS LINING MATERIAL COMPATIBLE WRH 100%MEIMANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑1 POLYEMENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑A FIBERGLASSREINFORCEDRA5M PROTECTION ❑5 CATHODIC PROTECTION ❑91 NOM: ❑95 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 0 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U %UNKNOWN A U 99 OTHER B.CONSTRUCTION A@ 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U %UNKNOWN A U %OTHER A U 1 STEEL/IRON A@ 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(MC) A U A FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A 0 6 CONCRETE A U 7 STEELCLAD W/FRP A U B 11X711 METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U %OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P { 12 VISUAL CHECK P®2 INVENTORY RECONCILIATION F { 3 VADOSE WELLS P B A ELECTRONIC MONITOR P B 5 GROUND WATER MONITORING WELLS { 5 PRECISION TES TING P S 7 PRESSURETESTING P B 91 NONE P B 95 UNKNOWN P { 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE UST USED(MO/YR) 2. ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN OALLONB INERT MATERIAL? ❑YES E]NO THIS FORM HAS BEEN COMPLETED UNDER PEN ERJU ,A TO T E B�VPF MY KNOWLEDGE.IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE L G o r1Sfl>J LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID N 10 3 CURRENT LOnCAL�iY FACIDI APPROVED BY NAYS PHONE•WITH AREA CODE �< V k- ILITY PEIIMR NUMSER PERMR APPROVAL DATE P[RMR EKPMATION DATE CHECKS PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT S BY: 1 FORMBIB29BBI THIS FORM MUST KACCOWAMSn9YAFACBRYHREAPPS=TION, FORM'A',UMLESSACI R f FOMW HASBEENFAUED 1 DATA I—,CESSING COPY 2 LOCALAOENCYCOPF .—j FIIECOPY