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STATE OF CALIFORNIA WATER RESOURCES CONTROL "OARD FORM `B': UNDERGROUND STORAGE TANK PRO"AM TANK TANK PERMIT APPLICATION INFORMATION .. COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT RRr5 CHANGE OF INFORMATION ❑7 PERMANENTLY CTANK ONE ITEM ❑ 2 INTERIM PERMIT F-14 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE E:18 TANK REMOVED lS FACILITY/SITE NAME WHERE TANK IS INSTALLED: T673 t.uwLJ FARM TANK-YES❑ NO Pvr 7 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 10 A. OWNERS TANK ID#O Z IB. MANUFACTURED BY: W C. YEAR INSTALLED 1t"+`/ D. TANK CAPACITY IN GALLONS: 6 11. TANK NTENTS IF IRA),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM I A MI MOTOR CLE 1 UNLEADED V] 2 ED E] 3 DIESEL A ❑3 CHEMICAL PRODUCTE]E]4 OIL ROLEUM B 1 PRODUCT C ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN REM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&( 6A C.A.S.# IQ Jill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A 7YPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EKIERIOR LINER ❑95 UNKNOWN SYSTEM 14GLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER C ,STEELARON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS F-]4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK MATERIAL ❑5 CONCRETE E]6 POLYVINYL CHLORIDE F-17 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ I RUBBER LINED ❑ C.INTERIOR AU(YD UNING F-13 EPDXY LINING E]/PHENOLIC LINING LINING F-15 GLASS UNING 6 UNLINED ❑ 95 UNKNOWN Y� ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYLWRAP ❑4 RBERGLASS REINFORCED PU$iIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U SUCTION 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 U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM ACONCRETE A U 7 STEEL CLAD W/FRP A U 8 1 OD%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A k05 UNKNOWN A U 99 OTHER ''''�A✓`//�'''1�Y./ LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. V P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 6 5 GROUNDWATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S W OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DA E ST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED ITH SUBSTANCE REMAINING IN GALLONS INERT MATT14 ❑YES ❑ NO j THIS FOM AAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1 TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION N AGENCY M FACILITY ID# TANK ID# ® = = 1 01 D 1 11 (. z 010 10 1 Z CURRENT LOCAL AGENCY FACILITY IDN APP Y AME PHONE#WITH AREA CODE rl PERMIT NUMBER PERMIT APPROVAL DA PERMIT EXPIRATION DATE \ \! CHECK N PERMIT AMOUNT 4.- 7111CIa1RGE AMT* W. NFEE CODE I RECEIPT# BY: FORM 8(3 7-8e) THIS FORM MUST BE ACCOMPhielfRY A FACH ITYISITE APPLICATION, FORM 'A',UNLE CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY