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, STATE OF CALIFORMR WATER RESOURCES CONTROSOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMP ETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ®5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑N AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED o / FACILITY/SITE NAME WHERE TANK IS INSTALLED: DAVIS FARM TANK-YES❑ NO JXI I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK IDM TTMVMnWN B. MANUFACTURED BY: OWEN CORNING C.YEAR INSTALLED 1990 D. TANK CAPACITY IN GALLONS'. 12,000 11, TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. A.fD 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ® 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT [jA OIL 0` 1 PRODUCT ❑K 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 6 C.A.S.N C.A.S.A. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN SOK A.B,C.S D A TYPE OF R I DOUBLE WALLED ❑3 SINGLE WALLED WITH OIERAR LINER ❑ 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑A SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEELIIRON ❑2 STAINLESS STEEL X©3 FIBERGLASS ❑K STEELCLAD W/FIBE T ' � I.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑8 1006 METHANOL ' MATERIAL ED 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER LINING ®scLAsspNING LINED ❑❑6UNUNEDLINING ❑ 3EPDXY uwwG %PHEL' "NI ENVIRONMENTAL HEALTH C. INTERIOR ❑ IS LINING MATERIAL COMPATIBLE WITH IOAMETIUNOL7 E]YES E:]NO E]99 OTHER PERMILSERViCES D.CORROSION ❑ 1 POLYEf16ENE WRAP ❑2 TARORASPHALT ❑3 VINYL NMP ❑1 RBEAGLASSREINFORCEDPIASTIC 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 I SUCTION cu 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U W OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U % UNKNOWN A U N OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHIORIDE(PVCI U FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5ALUMINUM A U 6CONCRETE A U 7STEEL CLAD W/FRP A U 91809 METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U N OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. t t VISUAL CHECK P t 2 INVENTORY RECONCILIATION P t 3VADOSE WELLS06 A ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS ((! P 6 PRECISION TESTING P 7 7 PRESSURE TESTING P t 91 NONE P t 95 UNKNOWN P t 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE t ESTMATED DATE UST USED(MO/VRI 2. ESTIMATED OIJANTITY REMAINING 7. INE TANK MATERIFILLED MATERIAL'N/A SUBSTANCE REMAINING IN NSA OALLONt INERT MATERIAL?N/A ❑VE$ ❑ NO N/A THIS FORM HAS BEEN COMPLETED Ut4DER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED UR DATE q HELEN LORETO �0S LOCAL AGENCY USE ONLY COUNTY N JURISDICTION t AGENCY 1 FACILITY ID N TANK IO N UM = = I I a rid CUPRENT7 AGENCY FACILITYID APPROVED tY NAME G(J/10 PIONE N WITH MG CODE PEIIMR NUYtER /7h PERMIT APPROVAL DATE PERMIT EXPPRATON DATE CHECKN PERMIT AMOUNT SURCHARGE AMT. PEE CODE R[CEIRP aY: FORMB(8-n-88) THIS FORM MUTTKACCWAMED SY AFACBIIYNIIEAmrA10K FORM'A',IMILEIMACIIII6R FQMlN HASIEENFILED r � I r. r�i lj 1 DATASCESSING COPY 2 LOCAL AGENCY COPA FLE COPY `�� _