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STATE OF CALIFORNI#%. WATER RESOURCES CONTROL wmRARD FORM 'B" / UNDERGROUND STORAGE TANK PROGRAM #98632C TANK C� TANK PERMIT APPLICATION INF MATION (a COMPLETE A SEPARATE FORM WITH THE FOLLOWING IN NATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ®3 RENEWAL PERMIT ql<&ANGE OF INFORMATION ❑ 7 PERMANENTLY CL ONE ITEM ❑2 INTERIM PERMIT ❑S AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED I FACILITY/SITE NAME WHERE TANK IS INSTALLED: GT3TIIITTIB CIICYTOn FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID p 77C B. MANUFACTURED BY: XERX C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 10,000 gallons 11. TANK CONTENTS IF(Ai),IS MARKED,COMPLETE REM C.IF(A.11,18 NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑1 UNLEADED ®2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑0 OIL [m1 PRODUCT ❑A GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 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.0 CAS_S: 8006619 III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,A D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ® 2 SINGLE WAU.ED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESSSTEEL 3 FIBERGLASS ❑d STEEL CLAD W/FIBERGLASS REINFORCED FUSTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑T ALUMINUM ❑B IXR,METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER— hECEIVED ❑ 1 RUBBERLINED ❑2 ALKYO LINING ❑3 EPDXY LINING ❑ I PHENOLIC LINING C. c LINING IR F--] 5 GLASS LINING ®6 UNLINED E]95 UNKNOWN NVlRUNMENTAL H AL.T ❑IS LINING MATERIAL COMPATIBLE WITH 109%METHANOL? [::]YES ❑ NO ❑99 OTHER SJ` 0.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TARORASPHALT F—]3 VINYLWRAP ❑4 RBERGLASS REINFORCED RAM PROTECTION ❑ 5 CATHODIC PROTECTION ®91 NONE ❑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 W 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION AU 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U %UNKNOWN A U MOTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A A FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B IODR METHANOL 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. S I VISUAL CHECK U S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P E I ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS PQ 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P E 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE t. ESTIMATED DATE LAST USED(MONI) 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 PERJUR D H T OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED A SIGNATURE) DATE DAkJID & TGHNSoo b LOCAL AGENCY USE ONLY COUNTY S JURISDICTION N AGENCY E FACILITY ID R TANK ID S U�� = = I I I /10 3 CURRENT LOCAL AGENCY FACILITY ID P APPROVED SY RAVE PHONE P WITH AREA CODE VIC s PERMIT NUMBER PERMIT A04 IOYAL DATE PERMIT EXPIRATION DATE CHECKS PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIR E BY: ,V/ ` NRj FORM B(6 N N) THIS FORM IRW R ACCOBBAMB—FACamroTE APwr1YpK FORM'A',UKM A C" FORM M IW BEEN FLED 1 DATA PAC IV SING COPY 2 LOCAL AOENCY COPT "3"'O LE COPIY �r�,