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STATE OF CALIFORNIO WATER RESOURCES CONTRCSOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM QO TANK PERMIT APPLICATION INFORMATION TANK oc, COMPLETE A SEPARATE FORM WITH THE FOLLOWIN INFORMATION FOR EACH TANK. Z MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWALPERMIT Efis CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 10 ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: c,.�,' '' w �l�Vl/le/✓L. / /Z" LO1-C- FARM TANK-YES❑ NO N 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY C:) A. OWNERS TANK IDN B. MANUFACTURED BY: axlkrwu L, O C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: / SO D II. TANK PONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. UNLEADED E]2 LEADED ❑3 DIESEL B. ❑3 CHEMICAL PRODUCT ❑ 4 OIL I PRODUCT ❑4 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&C.A.S.N C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A TYPE OF ❑I � � F]WA3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/810N ❑2 STAINLESS STEEL [j3 FIBERGLASS E]4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.MAATERIAL ❑ 5 CONCRETE ❑6 POLYVINYL CHLORDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOUCUNING LINING ❑ 5 GLASS LINING ❑5 UNLINED �95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH ION,METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 WYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE Q 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 U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 9 NKNOWN 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 KNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM6 CONCRETE A U 7 STEELCLADW/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 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 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 LECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 6 8 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P 9 NKNOWN P S 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? E]YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# IJUURISSDICCTIIONNN ff��AGENCY# FACILITY ID N TANK ID N O"\ L—LJJ L � U r7 v 2 v / b o v v G E ENCY FACILITY IO N APPROVED BY NAMEPHONE M WITH AREA CODE s ou rH.2� a-7-9D PERMITAPPROVALDATE PERMIT EXPIRATION DATE PERMITAMOUNT SURCHARGE AMT. FEE CODE CEIPTN FORM O(629-39) THIS FORM MUST BE ACCOMPANIED BYAFACILITY/SITE APPLICALON, FORM 'A',UNLESSACURgENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY