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SAN�JOAQUIN LOCAL HEALTH DISTRICT 1601 E. Hazelton Ave. , P. 0. Box 2009 Stockton. CA 95201 (209) 466-6781 Jogi Khanna, M.O. , Health Officer STOCK54 WAGNER CORPORATION FORMERLY STOCKTON DODGE P. 0. BOX 334 540 N. HUNTER STOCKTON, CA 95201 STOCKTON, CA - .,.:.•y.,*w ,Ar'h.wp;;t;yyy,w,`•...,, 9Kr54- •..•r " . ,-va--Na,- - -, _... STATE OF CALIFORNn WATER RESOURCES CONTROARD FORM B': UND GROUND STORAGE TANK PR AM " TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. t0 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE STANK REMOVED Q W FACILITY/SITE NAME WHERE TANK IS INSTALLED: I O In n FARM TANK-YES❑ NO fV (D I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A A. OWNERS TANK ID q9 WIL- B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS 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 F-]3 CHEMICAL PRODUCT _1 P4 (L F-11 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN �E ❑7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF /,y^,/^)l�9,1 HAZARDOUS SUBSTANCE STORED&C.A.S.# 1'��'^� a( C.A.S.W III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,6 D A TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNEP 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 SIERPRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑ 8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEELUNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑1 AUKYDUNING ❑3 EPDXYUNING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED .�1NKNOWN � d E:] IS LINING MATERIAL COMPATIBLE WITH10D%METHANOL? [—]YES [—] NO �9d9iflER Ld K-A-- D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYLWRAP ❑ 4 RBERGLAS4 REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONEUNKNOWN ❑ N OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IFUNDERGROUND,BOTH IFAPPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE UNKNOWN A U 99 OTHER S.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLWINYLCHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM CONCRETE A U 7 STEELCLADW/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL AQp 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 S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS 8 4 ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 6 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF F 3. WAS TANK FILLED WITH �— SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? [—]YES E] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED B SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY a FACILITY ID N TANK ID N Ehl = = I do coo CURRENT LOCAL AGENCY FACILITY IDR O APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER 1T PERMIT APPROVAL DATE fIPERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: �-'' FORMe(s-29-BBI THIS FORM MUST BE ACCOMPANIED�BY A FACILITY/SITE APPLICATION, FORM `A',UNLES$wCURRENT FORMW HASBEENFILED DATA PROCESSING COPY .