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STATE OF CALIFORN' WATER RESOURCES CONTR( 30ARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM r A wl V TANK PERMIT APPLICATION INFORMATION FU'M n COMPLETE A SEPARATE FORM WITH THE FOLLOWIN FORMATION FOR EACH TANK. __UUO" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED NK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: LA FARM TANK - YES NO I. TANK PTION COMPLETE ALL ITEMS -IF UNKNOWN -SO SPECIFY II. TANK CONTENTS :vu r or m n IR NnT MARKED- COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM e. A. OWNERS TANK ID R VIL_ B. MANUFACTURED BY: (Jr__ C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 100-f5� II. TANK CONTENTS :vu r or m n IR NnT MARKED- COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM e. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW( D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF HAZARDOUS SUBSTANCE STORED & C.A.S. # C.A.S. R: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D Z 10 A. TYPE OF ❑I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 1:9/95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W19BERGLASS REINPORCEO PLASTIC B. TANK ❑ 5 CONCREIT ❑ 6 POLYVINYLCHLORIDE ❑ 7 NUM ❑ 8100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BNONZE ❑ 10 GALVANIZED STEEL LZ95 UNKNOWN ❑ 99 OTHER A ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PH CLINING C. INTERIOR LINING ❑ SGLASS LINING NING 6lINUNED 2 STAINLESSSTEEL UNKNOW N U 3 POLYVINYL CHLORIDE (PVC) A U ❑ ISURING MATERIAL COMPATIBLE WITH 10091 METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POUYEIHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 MNY ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE NKNOWN ❑ 99 OTHER IV. ... (SYSTEM "•A • V` ✓U qI I I a 3 4/ A TYPE U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 95 UNKNOWN A U 99 OTHER B CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH A U 91 NONE A 5 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A CONCRETE A U 7 STEELCLADW/FRP A U 8100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 111kkk```�Ikk"'''" 5 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETEenuN aTsIEM Mubt Pc m you. P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P B 91 NONE 8 95 UNKNOWN P 8 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 F( nnAl Al IM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND C APPLICANT'S NAME (PRINTED 8 SIGNATURE) DATE :KI!%V I ICF nkil V YHtC 1. COUNTY # JURISDICTION # AGENCY P FACILITY ID R TANK ID 6 qI I I a 3 4/ CURRENT LOCpQAGENCY FAFILITj'pA / APPROVED BY NAME PHONE A WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE I PERMIT EXPIRATION DATE I CHECK A PERMIT AMOUNT SURCHARGE AMT. I FEE CODE I RECEIPT k .��..-....�_n... �.nu,a vi^u C^O&A lAl uui Ccc -. 100CNT UnDM'A' MACRCCM DATA PROCESSING COPY