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STATE OF CALIFORNh..— WATER RESOURCES CONTROL' dMRD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM #98632B -a r` TANK TANK PERMIT APPLICATIONI FORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWIN FORMATION FOR EACH TANK. ' MARK ONLY ❑ I NEW PERMIT ©3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL roAN ONE ITEM ❑2 INTERIM PERMIT ❑d AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED O FACILITY/SITE NAME WHERE TANK IS INSTALLED: GT3T111IIOC ChCVTOD FARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK IDM WC6377C B. MANUFACTURED BY: XERX C.YEAR INSTALLED 1984 D. TANK CAPACITY IN GALLONS: 10,000 gaRons IL TANK CONTENTS IF(A.1),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 ❑ 1 OIL O 1 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 6 C A.S.N CA.&N 8006619 III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN SOX A,B,C,A D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM X❑2 SINGLE WAUID ❑/SECONDARY CONTAINMENT ❑99 OTHER TANK F-] 1 STEEL/IRON ❑2STAINLESS STEEL 3FIBERGLASS ❑1STEEL CIADW/FIBERGLASS REINFORCED PUSTIC B.MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑1 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN 99 OTHER ❑ I RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑/PHENOLIC LINING C. INTERIOR JUN 2 7 ±930 LINING ❑5 GUSS LINING ®6 UNLINED ❑95 UNIOIOWN ❑IS LINING MATERIAL COMPATIBLE WITH IOD%MEIIMNOL7 ❑YES E:]NO E]99 OTHER IVVIk()NMFN-FAL HF AL H D.CORROSION ❑ I POLYETHLENE WRAP ❑2 TAA OR ASPHALT ❑3 VINYL WRAP ❑A FIBERGLASS REINFORCED PLASTIC 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 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION AU I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) AW 0 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 100%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. P^2 1 VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P E I ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS ,a 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P E 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE UST USED(MO/YR) 2 ESTIMATEDOUANTITYOFOALLOMB 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENAL PERJURY D To TPIEBT F MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE DL11,D ToHNSo, - I LOCAL AGENCY USE ONLY C�OU(NTY# JURISDICTION N AGENCY N ILITY ID S TANK ID N 17 I I I I lib 160 CURNEW LOCAL AGENCY FACILITY 10 N APPROVED EY NAME PHONE•WITH ARG CODE cIR � PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHEMO PERMIT AMOUNT WRCHAROE AMT. MEC ODE RECEIPTP FORM B(6-29fiB) THIS FORM MUSTS!AOCOrAN/ "AFAC81fYApR APIBlCJTKIII FORM'A',UMtEB{AC -'T F01111111A' IMS BEEN FILEDD \ 1 DATA PROCESSING COPY 2 LOCAL AGENCY COoIF -3—PILECOPY