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STATE OF CALIFOR� WATER RESOURCES CONT OARD FORM `B': UN GROUND STORAGE TANK PRRAM � p TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWIN 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 ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE FACILITY/S8 TANK REMOVED ITE NAME WHERE TANK IS INSTALLED: C.J FARM TANK-YES NO ❑ ,rl7 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# Lle CIT - B. MANUFACTURED BY CA) C. YEAR INSTALLED �[� D. TANK CAPACITY IN GALLONS: sa- II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. ❑ ❑ 2 LEADED 3 DIESEL 1 UNLEADED ❑3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL E] g9 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.# C.A.S.#. 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D rA.TYPE OF ❑ 1 DOUBLEWALLEO ❑3 SINGLE WALLED WITH EXTEfl10R LINEA 5 UNKNOWN TEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC KERIAL ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE ERP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PH LIC LINING LINING ❑ 5 GLASS LINING E] 6 UNLINED UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH I X%METHANOL? ❑YES NO ❑ g9OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TARORASPHALT ❑ SS WRAP ❑4 FIBERGLAREINFORCEDPLASTIC PROTECTION E]5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑gg OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOT HIE APPLICABLE EE A U 1 SUCTION A U 2 PRESSURE p U 3 GRAVIN 91 0 A U 1 SINGLE WALLED A U 2 DOUBLE WALLED p U 3 LINED TRENCH A U 91 NONE A 5 UNKNOWN A U 99 OTHEOTHE RA U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINY CCHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONEA U 5 ALUMINUM A U CONCRETE A U 7 STEEL CLAD W/FRP A U 9GALVANIZED STEEL A UNKNOWN A U 8 100%METHANOL COMPATIBLE FRP 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 I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VAD BE WELLSP 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN 3, WAS TANK FILLED WITH GALLONS INERT MATERIAL? E]YES 0 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION# AGENCY# FACILITY ID# TANK ID N � 6 CURRENT LOCAL AGENCY FACILITY ID ,/(/I)6z zc- APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECKN PERMIT AMOUNT SURCHARGE AMT. FEE CODER IPTM BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMP I3 A FACILITY/SITE APPLICATION, FORM `A',UNLE CURRENT FORMA HAS BEEN FILED DATA PROCESSING COPY