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STATE OF CALIFORNI WATER RESOURCESCONTRC `OARD FORM 'B': UNDERGROUND STORAGE TANK PROMAM TANKTANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. IC MARK ONLY �1 NEW PERMIT ❑3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED 0 FACILITY/SITE NAME WHERE TANK IS INSTALLED: i8�� / %'�C FARM TANK-YES❑ NO N I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY GA1 A. OWNERS TANK IDN 0 1 B. MANUFACTURED BY: A C.YEAR INSTALLED O TANK CAPACITY IN GALLONS: II. TANKCONTENTS IF(A.1),IS MARKED,COMPLETE ITEM 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 ❑ 4 OIL [Z?�PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑8G EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.4 N C.A.S.M III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A. TYPE OF ❑ 1 OUBLE WALLED ❑ 351NGLE WALLED WITH EXTERIOR LINEA ❑ 95 UNKNOWN SYSTEM VNGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 IDD%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER ❑ 1 NIBBERUNED ❑�2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING C LINING INTERIOR ❑5 GLASSUNING I_J"UNUNED ❑ 95 UNKNOWN ❑ISUNING MATERIAL COMPATIBLE WITH 100%MEIHANOL? ❑YES [j NO ff99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑r�L2 TARORASPHALT F-13 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION E] L.IL�"'5 CATHODIC PROTECTION NONE V.5 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF AB EGROUND. U IF UNDERGROUND.BOTH IF APPLICABLE A.SYSTEM TYPE A i RUCTION U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION U 1 SINGLE WALLED 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPEA U 91 NONE C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHNOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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 1VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS 6 PRECISIONTESTIN P S 7 PRESSURETESTING P 8 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2.EST ATED OUANTTTY OF 3.WAS ANK FILLED WITH NCE REMAINING IN N ATERIAL7 YES E] NO GALLONS THIS FO HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOW EDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY 4 JURISDICTION# AGENCY# FACILITY ID# TANK ID# m n-n d o U o � III APPROVED BY NAM PHONE#WITH AREA CODE CUR(R/EN�T-LIOCAL ADEN FAQILITY IDM I A KA PERMIT NUMBER Z�aj /P�ERMIT APP OVAL TE PE MITE IRATIONDATE 2,0 19 CHECK# PERMIT AMOUNT SURCHARGEANY. FEE CODE RECEIPT# BY: FORMB(6-29.88) THIS FORM MUST BE ACCOMPANIa YAFACILITYDA A PROTION, FGORM 'A',UNLE #RENT FORM'A' HAS BEEN HIED —