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STATE OF CALIFORN1 7 WATER RESOURCES CONTF BOARD FORM 'B': UNDE=RGROUND STORAGE TANK PRUGRAM TANK TANK PERMIT APPLICATION INFORMATION (a COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z 10 MARK ONLY ❑ 1 NEW PERMIT [73 RENEWALPERMIT R-5-"CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEDT ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED I i ' FACILITY/SITE NAME WHERE TANK IS INSTALLED: 11E1 FARM TANK-YES❑ NO ❑ (a I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# G3 B. MANUFACTURED BY: �s.�Liytl►7K..� n0 C.YEAR INSTALLED 7 D. TANK CAPACITY IN GALLONS: noev 11. TANK CONTENTS IF(ALT),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A F-1 1 MOTOR❑ 3 CHEMICAL PRODUCTCLE F-1F-1 4 OII"LROLEUM B.F-1 1 PRODUCT C ❑ 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑4 GASAHOL ❑5 JET FUEL ❑8 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.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,E C,8 D A TYPE OF ❑ I DOU EWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM kf jlfEINGUE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEER IRON ❑2 STAINLESS STEEL F-] 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL lkiCONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8188%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 18 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER F-11 RUBBER LINED ❑2 A ING ❑3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING C.L ❑ 5 GLASS LINING UNLINED ❑ 95 UNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO �OTHER uyl D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TA ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION 1 NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IFAPPLICA13LE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE 3 GRAVITY A U 91 NONE A U 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 5 UNKNOWN A U 99 OTHER 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 C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A d)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. e/ P S 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS LIII/1P//'ill' P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING ein91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/VR 2. ESTIMATED OUANTITY OF 3. WAS TANK FILLED WITH //Cw/X/ SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E]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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 3y a CURRENT LOCAL AGENCY FACILITY ID APPROVED BY NAM PHONE#WITH AREA CODE 'g.3 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATISIN bATE CNECK f PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT* BY: FORM S B-29-881 THIS FORM MUST BE ACCOMPANIEL-Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RRENT FORMA HAS BEEN FILED DATA PROCESSING COPY i