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TATE OF CALIFORNIP WATER RESOURCES CONTROI '^ORD FORM 'B'., UNDEku'ROUND STORAGE TANK PROD rrAM TANKTANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK Z 10 MARK ONLY ❑ t NEW PD9Mrt ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 ENnr tx ONE ITEM 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑6 TEMPORRA�IRY TANK CLOSURE B TANK REAOVED o -- FACILITY/SITE NAME WHERE TANK IS INSTALL F0- ��D <OS 1 /`�"a'G FARM TANK-YES❑ NO -1 1� 1 TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY C0 �7 — CO A OWNERS TANK 10t v B. MANUFACTURED BY: / y C.YEAR INSTAIIEiD G/ ( D. TANK CAPACITY IN GALLONS. TANK CONTENTS IF(Al),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. A ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 1 OIL ❑ 1 PRODUCT ❑1 GASOHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑BO EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF CA.S.I: HAZARDOUS SUBSTANCE STORED 6 CAS.II I. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,\D } A TYPE OF ❑1 DIABLLWNIE7 ❑3 SINGLE WALLED WITH E%IERIOR LEER ❑951W(NOWN SYSTEM ❑2 SINGLE WILLED ❑1 SECCH1A19'CONTNNLEJR ❑99 OTHER 1 SI133 " 2STMES5 SIS 3FID90ASS ❑'4 OR CLAD WIRBEAGAM RUMORCED RASRC S.TANK 5 CONCRETE ❑6 POLYamatoRDE ❑ 7&LMWM ❑6 100%WTHWOLCOUPARBLERIP MATERIAL 9 BRONZE ❑ 10 GALVANUEDsm ❑95 UNKNOWN ❑99 ORIER ❑1 N6BEA LN® ❑2 AU(YD UNNG ❑3 EPDXY LxIN(I ❑A RL71000 UI9NG G INTER1011 5 Eum uw G F-16 OLIN® ❑95 LP9m" LINING DIS USING MATBML COWATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 PoLYETHBEWWkP ❑2 TAA OR ASPHALT ❑3 VINYL MLU ❑t FIBERGLASS REWIDAM RASVC PROTECTION ❑5 CATHOLIC PROTECTION ❑ 91 NONE ❑95 UKIYNAI ❑99 DTH M -V. 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 U 95 UNKNOWN A U 99 OTHER IL 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 99 OTHER A U 1 STEEUYTON A U 2 STAINLESS STEM A U 3 POLYVINYL CHLONDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A M 6 CONCIETE A U 7 STEELCLAD WUFRP A U S 100%METTWNOL COMPATIBLE FRP A U 9 GALVANIZEDST7$ A U. 95 UNKNOWN A u 99 OTHER /. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY.OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. r 6 T Vl CHECK r s 2 VYvENTORY7TEf.ONCNlATK9N p s 3 VADOSE WELLS r 6-4 ELECTRONIC TON r s 6 DROUNO WATER MONITONNG WELLS P s a PREC751DH TESTING P S I PRESSURE TESTING r s 91 NOW r s e UNKNOWN r s W OTHER -/1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.-ESTWATEDDATE LAST USED(MO/YR) - 2.ESTIMATEDOUANTITY'OF - -3 WAS TANKFILLED WRH - -SUBSTANCE REMAMUNO N - INERTuATENALI--- ❑YES ONO OKLOMS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OFPERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND.CORRECT - APIRUCANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY S JURISDICTION S AGENCY/ FA(CI�LITY ID P TANK ID i F CURRENT LOCAL AGENCY FACUJT/ID APPROVED ST MAYS PHOME I WITH AREA CODE tir�3 PERMIT MUMMA PEMYR APPROVAL DATE PFA WT EXPIRATION DATE `� sr: - Z CHECK PERWT AMOUNT - SURCHARGE AMT. FEE CODE —CEIPT• !� ___.._..r.__. •..,c moo ui,cT Pc arrnuoANmn...AtAnII1Y7SrtF 1DPLK:1nON. FORM 'A'.UNLESS A CURRENT FORMA' HASBEENFRED L