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G TATE OF CALIFORNIA WATER RESOURCES CONTROL - ORD FORM 'B': UNDERUAOUND STORAGE TANK PRO(.xrfAM QO COMPLETE Z TANK TANK PERMIT APPLICATION INFORMATION A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. O MARK ONLY ❑ t NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANCE OF INFORMATION 7 PERMANENTLY CL ❑ ONE ITEM 2 INTERIM PERMIT ❑E AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED '� C'o FACILfTY/SITE NAME WHERE TANK IS INSTALLED: �j Q Q �• COS7 - FARM TANK-YES NO ❑ (V O I TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 57S^ O v cn i A OWNERS TANK IDE B. MANUFACTURED BY: UK , C, YEAR INSTALLED u XD. TANK CAPACITY IN GALLONS: TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM e. C- ❑ t UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ E OIL ❑ 1 Pfl00l1CT ❑E GASAHOL ❑ 5 JET KIEL ❑6 AVIATION GAS ❑ 5 FIAZAMOI7S ❑80 DAPTY ❑95 UNKNOWN ❑2 WASfE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUE1,ENTER NAME OF CAS.E: HAZARDOUS SUBSTANCE STORED 6 CAS E I. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C.A D ECDRR0S*WM ❑I DOLBLEWALUD ❑3 SINGLE WALLED MTH E%IERIOR LOFR ❑95 UW4OWN ❑2 SWGLEWXLED - - ❑N SECONDARY COWAN" ❑99 OTHER ❑ I STE.fLOpN ❑2 STANEM MR ❑3 FIBEROLK% 'C]N MR CLAD W/FIBERGUSS REWORDED RASVC ❑5 CONGER ❑6 POLYAMCIADIDE ❑7 M AIRIM ❑B'OD%METH*a COMPATIBLERW L. ❑9 BRONZE ❑ 10 GALVANZED sm ❑.95 IE wm ❑99 Ono ❑ 1 R mi-tFD ❑2 ALMUNNG ❑3 EPWLMC ❑NR 5 GLAR5l9DNG ❑6 UIUI® ❑95 IEOw" ❑❑ISUNWUAT94ALCOWAMEWITHlomwmNoL1 ❑YES 0NO ❑99 OTHER ION ❑I PaYEnI WRAP ❑2 TM OR ASPHALT ❑3 YOTTLWRAr ❑N fBERGlAS5fE0F01C®RASTCTION ❑5 GIHOOIC RgTECT10N ❑91 IIOIE ❑95 UMma ❑%OTHER _V. PIPING INFORMATION CIRCLE A IF ABOVE GROUND.U TFUNDEAGROUND.1BOTHIFAPPUCABLE— A SYSTEM TYPE A U I SLICTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE --A U 95 UNKNOWN A U 99 OTNOt B.CONSTRUCTION A U 1 SINGLE WALLED - A U 2 DOUBLE WALLED A U 3 ONED TRENCH A U 91 NOW A U % UNKNOWN A U IN OTHER A U I STEEL/93ON A U 2 STAINLESS STE$ A U 3 POLYVINYL CHILOODE(PVC) A U 9 NBEItQLAS PIPE A U 91 NONE G MATERIAL A U S ALUMINUM A U 6 CONCH E A U 7 STEEL CLAD W/FHP A U 8 169Y METHANOL COMPAT'B E R9' A U 9 GALVANZED STEEL A U %UNKNOWN A U 99 OTHER J. LEAK DETECTION SYSTEM CARCLE P FOR PRIMARY.,OR s FOR SECONDARY.A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. Z 1 VLR CHECK • S 2 9fVENTONf RECONCR1ATKw • 6 3 VADOSE WELLS • 6 1 EyECTR )C MOWTOR • 6 5 GROLNND WATER MONITORING WELLS E 6 B PRECL ONTESTING P 6 7 PRESSURETESTING • 6 91 NONE • i 95 UNKNOWN P Z W OTHER _ -VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I.ESTIMATED DATE LAST USED(MO/YR) z SUBSTANCE W-MA" a 3wAS TANKE97ED wrtH suGsrAwcE...:-sir:w OALL0NN9 INERT 4ATEf9AL7 ❑YES E]NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MT'KNOWLEDGE,1S TRUE AND CORRECT. DATE APPUCANTS NAME(PLANTED 6 SIGNATURE) PLA LOCAL AGENCY USE ONLY COUNTY A JURISDICTION E AGENCY E FACILITY ID 6 G TANK ID 9 CVRRENT LOCAL AGENCY FACULTY ID M APPROVED 8Y NAME PHONE I WITH MEA CODE PEAYR NUY6ER PERYR APPROVAL GATE PERYR E)IPIMnOM DATE /�. {. �� O PERMIT AMOUNT 9URCHMGE AMT. FEE CODE CHECK M F(TRM 'A'-UNLESS A CURRENT FORMA' HAS BEEN FILED