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STATE OF CALIFOlVit WATER RESOURCES CON-j4LOARD FORM B': UNDERGROUND STORAGE TANK PROGRAM �; _ = TANK TANK PERMIT APPLICATION INFORMATION ( a COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACHI TANK. 1 CJ MARK ONLY ❑ I 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 ❑8 TANK REMOVED // CA1 FACILITY/SITE NAME WHERE TANK IS INSTALLED: fAMCA (173 9- LDai£r {Jy9YYra# FARMTANK-YES NO ❑ C.-Li I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY CO A. OWNERS TANK ID#, ems /J � {Ay 7-e t YZ1GINNSC{IraIZ B. MANUFACTURED BY: /'LAe�- K-110 01L C YEAR INSTALLED �'O� /T-F-` D. TANK CAPACITY IN GALLONS: IL TANK NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(At),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. L] i UNLEADED ❑ 2 LEADED DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS E]5 HAZARDOUS E] 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&C.A.S.9 C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINEA 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEUTAON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 LUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER ME F-1I RUBBER LINED ❑ 2ALKYD LINING 3EPDXY LINING E] 4 PHENOUCUNING C LIN NRG R ❑ 5 GLASS UNING ❑6 UNLINED UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 1 O METHANOL? ❑YES ❑NO ❑ 99 OTHERJ U N 2 0 1207 LJ D. CORROSION ❑ I POLYETHLENE WRAP 2TAR OR ASPHALT ❑ 3AWL WRAP El FIBERGLASS REINFORCED PLASTI6�T pp 11 V IR I 1 PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER PERMIT/SFRVICES IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A n95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON 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 V_6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 995 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLEPOR PRIMARY,OR S FOR SECONTIARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P B 3 VAOOSE WELLS P 5 4 ELECTRONIC MONITOR P 6 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING 1 NONE P S 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF 1 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YEG ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTFSIGNATURE DATE / LOCAL AGENCY USE ONLY COUNTY k JURISDICTION N II AGENCY k FACILITY ID P TANK ID N m L� CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE Y WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHI PERMITAMOUNT SURCHARGE AMT. FEE CODE 40CEIPTN BY: FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FO R M 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED