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STATE OF CALIFORNW WATER RESOURCES CONTROARD G FORMB': UND GROUND STORAGE TANK PRO RAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE ASEPARATE FORM WITH THE FOLLOWING NFORMATION FOR EACH TANK.'. o MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY Cif TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDEDPEflMIT 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVEAtU J FACILITY/SITE NAME WHERE TANK IS INSTALLED: gzzS ,Q-cA FARM TANK-VES NO El I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY co7 A. OWNERS TANK IDK B. MANUFACTURED BY: CL5 C. YEAR INSTALLED 0 D. TANK CAPACITY IN GALLONS: 11. TANK C TENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A.T),IS OT MARKED, IAIPLETE ITEM D. C� A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. I UNLEADED E]2 LEADED ❑ 3 DIESEL F-1B.3 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT E]4 GASAHOL ❑ 5 JET FUEL E] 6 AVIATION GAS [—]5 HAZARDOUS 80 EMPTY [:]95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED A C.A.S.R C.A.S.p: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A B,C,6 D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNE95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 AL NOM ❑8 IW%METHANOL COMPATIBLE RIP MATERIAL [:]9 BRONZE E] 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER C.INTERIOR F-11 RUBBER LINED [—]2 ALKYD LINING F-13 EPDXYLINING ❑4 PHENOUCUNING ��[ LINING ❑ 5 GLASS LINING ❑6 UNLINED EQ% NKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO rTHER D.CORROSION ❑ I POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑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 .0 95 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 95 UNKNOWN A U 99 OTHER V� 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 G MATERIAL 'A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 /00%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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 S 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER J4vI VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE LAST USED(MO7YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? [::]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 B SIGNATURE) DATE LOCAL AGENCY USE ONLY / COUNTY N JURISDICTION M AGENCY M FACILITY ID k TANK ID 8 CURRENT LOCAL AGENCY FACILITYID• APPROVED BY NAME PHONE At WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE p �p CHECKe PERMIT AMOUNT SURC/URGE AMT. FEE CODE RECEIPTF BY: FORM 8(8-29-68) THIS FORM MUST BE ACCOMPANI (A FACILITYISITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM W HAS BEEN FILED//(� DATA DonnCQQIwr_ rnov