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'141 t e CALIFO N�A WATER RESOURCES CO FORM 'B': L BOARD ND STORAGE TANK PROGRAM TANK C/ TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 5. i MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT ONE ITEM ❑ 2 INTERIM PERMIT/AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION El FERMAN& ❑ ❑ FACILITY/SITE NAME WHERE TANK IS INSTALLED: �/ _/ ' V :w 6 TEMPORARY TANK CLOSURE ❑g TANK REM( � I. TANK DESCRIPTION COMPLETE ALL ITEMS -IF UNKNOWN So SPECIFY(/� _-FARM TANK - YE A. OWNERS TANK IDR C. YEAR INSTALLED C7� ,� B. MANUFACTURED BY: II. TANK CONTENTS IF (0.1),18 MARKED, COMPLETE 1'.D_ TANK CAPACITY IN GALLONS: `}-) L, D` N A ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM M C. IF (0.1), IS NOT MARKED, COMPLETE ITEM D. ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ S HAZARDOUS 80 EMPTY B ❑ 1 PRODUCT G ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 4 GASAHOL 5 JET FUEL ❑ 95 UNKNOWN D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF ❑ 2 WASTE ❑ 6 AVIATION GAS 7 METHANOL ❑ ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW) HAZARDOUS SUBSTANCE STORED A C.A.S. p III. TANK CONSTRUCTION MAgK ONE ITEM ONLY IN BOK C.A.S. p: A B, C, i D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER SYSTEM ❑ 2 SINGLE WALED ❑ /SECONDARY CONTAINMENT 1:1 95 UNKNOWN B. TANK ❑ 1 STEEUIRON ❑ 2 STAINLESS STEEL 5 CONCRETE El MATERIAL ❑ ❑ 6 POLYVINYLCHLORIDE 3 FIBERGLASS ❑ 99 OTHER ❑ 4 STEEL CIA])W/FIBERGLASS REINFORCED FUSTIC ❑ BRONZE TO GALVANIZED STEEL ❑ ❑ 7 ALUMINUM ❑ 95 UNKNOWN 119 6 '"MEfHANOI COMPATIBLE INP C. INTERIOR ❑ 1 RUBBER LINED ❑ 2 NBYD UNING LINING ❑ 5 GLASS LINING ❑ 3 EPDXY LINING 99 OTHER ❑ 4 PHENOUC LINING ❑ 6 UNLINED ❑ IS LINING MATERIAL COMPATIBLE WITH IOD%METKWLI❑ ❑ YES ❑ NO 95 UNKNOWN D. CORROSION ❑ I POLYETHLENEWRAP ❑ 2 TAR OR ASPHALT PROTECTION ❑ 3 VINYL ❑ 99 OTHER 5 CATHODIC PROTECTION 91 NONE WRAP n o5 uuvunwu ❑ 4 FIBERGLASS REINFORCED FUSTIC 11 __ __ IV. PIPING INFORMATION CIRCLE AIF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION B. CONSTRUCTION A U I SINGLE WALLED A U 2 PRESSURE A U 3 GRAVITY A U 2 DOUBLE WALLED A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 9 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL C. MATERIAL -A U 5 ALUMINUM A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE A A U 6 CONCRETE A U 7 STEEL CLAD W/FRP LI 91 NONE A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U B 160Y METHANOL COMPATIBLE FRP A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PgIMAgY LEAN DETECTION SYSTEM MUST BE CIRCLED. P 6 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 6 3 VADOSE WELLS P 6 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 No P g 95 UNKNOWN VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE P B 99 OTHER 1. ESTIMATEDDATE LASn SUBSTANCE REMAINING INB. WAS TANK FILLED WITH LONS I INERT MATERIAL? YES THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT NO APPLICANT'S NAME (PRINTED A SIGNATURE) DATE COUNTY Y JURISDICTION �r� CURRENT LOCAL AGENCY FACILITY ID Y PEAYIT NUMBER CHECKY PEFIWTAMOUNT FORM B (649.86) THIS FORM MUST BE AGENCYY FACILITY ID Y MEAPE IPERMITAPPROVALDATE(APPROVALDAT SURCHARGE AMT. PERMIT EXPIRATION DATE TANK 1D Y 3 PHONE Y WIT" AREA CODE FEE CODE --F"--,PT By. . f : ,vPROCESSING COPY rMUAIIUN, FUHM'A', UNLESS DATA CUANENT FORM W HAS BEEN FILED U