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STATE OF CALIFORNIP WATER RESOURCES CONTROP -OARD FORM `B': UNDEftROUND STORAGE TANK PROMAM �' m TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT V5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED (T-61 6 FACILITY/SITE NAME WHERE TANK IS INSTALLED: e' C6er6ree FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY O A. OWNERS TANK ID# 3 B. MANUFACTURED BY: Gti C. YEAR INSTALLED C c-/'C' D. TANK CAPACITY IN GALLONS'. So W II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.i),IS NOT MARKED,COMPLETE ITEM D. co A. ❑ 1 MOTOR VEHICLE FUEL ❑�y2 PETROLEUM e. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ©I OIL PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS W ❑5 HAZARDOUS ❑80 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL [�J4 OTHER(DESCRIBE IN REM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# m d t 4,r of' ( C.A.S.M O 9 x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,8 D A.TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 9�BNGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER I ST UIRON E] 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGUSS REINFORCED PLASTIC B.TANK ❑ MATERIAL 5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBERUNED ❑ 2 ALKYD LINING ❑3 EPDXY UNING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING �UNUNED ❑95 U ❑ IS LINING MATERIAL COMPATIBLE"Ion METHANOL? ❑YES ❑NO OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TAR OR ASPHALT ❑3 JOWL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 2r95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION 7 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 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A&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 OP S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS ` P 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 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 ^ 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. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY k JURISDICTION# AGENCY# FACILITY ID# TANK ID B m = = i1ol / W-1010160o9 CURRENT LOCA AG;CYFACILITY 3D 5 APVgOVE BY NAMEOLIJ PHONE#WITH AREA CODE PERMIT NUMBER 33 PERMIT APPROVAL DATES 06PKIE%RMIITJ E_XMRATIONDATE CHECK p PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: �i Dana B,', nel THIS FOflM MUST BE ACCOMPAN AFACILITY/SITE APPLICATION, FORM `A',UNLESS RENT FORMA HAS BEEN FILED -