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STATE OF CALIFORNI& WATER RESOURCES CONTROARD FORM 'B': UND GROUND STORAGE TANK PR0 RAM TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. m MARK ONLY ❑ 1 NEW PERMIT E] 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED 0z FACILITY/SITE NAME WHERE TANK IS INSTALLED: 10941 FARM TANK - YES ❑ NO 1. TANK DESCRIPTION rAMPI CTF Al I ITFYC _ IC I IYYY wu nn n__ A. OWNERS TANK IDN B. MANUFACTURED BY: U AjtC- C. YEAR INSTALLED 'UA I(_ D. TANK CAPACITY IN GALLONS000 C r -Y SANK CONTENTS In IAll I. uwe.Fn «� A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL B PRODUCT C. NLEAOED ❑ 2 LEADED ❑ 3 DIESEL ❑ 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. # vl CAS k Al A. XIII. 1nnI%GUIY01HUGIIUN MARKONEITEMONLYINBOXA.B.C.&D A TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN SYSTEM ❑ 2 SINGLEWALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER U 3 GRAVITY A U 99 ❑ I STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE❑ 7 ALU M ❑ B 10096 METHANOL COMPATIBLE FAP U 3 LINED TRENCH A ❑ 9 BRONZE El 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER C. INTERIOR F -1I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXYLINING ❑ 4 PHENO LINING LINING ❑ 5 GU1SS LINING ❑ 6 UNLINED A UNKNOWN 5 ALUMINUM ❑ ISUNING MATERIAL COMPATIBLEWITH 100%METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VI RAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION [:]91 NONE 5 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION clan P e II A SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A UNKNOWN A U 99 OTHER PERMIT APPROVAL DATE 8 s Qylrj/ A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLWINYL CHLORIDE( PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 190% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A D5UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST RF r.IRnl Fn bis P 5 1 VISUAL CHECK POS 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CI nsFn IN DI ecc 1. ESTIMATED DATE LAST YSED �(M-O/YR) 2. ESTIMATEGALLONS D QUANTITY OF 3. WAS TANK FILLED WITH 1k I/ Y� SUBSTANCE REMAINING IN INERT MATERIALP ❑ YES Ej NO lCl F / THIS FORM HA BEEN COMPLFTPO IINF)FP PFAIAI TV nF PPa. a lav AhIn Tn Tar orcr nr I.I. 1..11-1 DATA PROCESSING COPY O 1"d u APPLICANT'S NAME (PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY CCOOUNNTTY# JURISDICTION # AGENCY R FACILITY ID R TANK ID c) c)v CURRENTrCAL AGENCY FACILITY ID # F APPROVED BY NAME PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE 8 s Qylrj/ P IT EXPIRATION DAtE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEECODE RECEIPT# BY. FORM B (3-7-68) THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM 'A', UNLESS AMBIENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY O 1"d u