SITE INFORMATION AND CORRESPONDENCE

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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD .•� ;�^ FORM B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION IN ORMATION COMPLETE A SEPARATE:FORM WITH THE FOLLOWIN ORMATION FOR EACH TANK. 1C MARK ONLY ❑ 1 NEW PERMIT F-13 RENEWAL PERMIT ff�w"HANGE OF INFORMATION 7 ERMANENTLY Cro ONE ITEM El INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED r C.r41 FACILITY/SITE NAME WHERE TANK IS INSTALLED: �}V FARM TANK-YES❑ NO w le 1�1LD I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN--SO SPECIFY }"s^ A. OWNERS TANK ID III B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS; 047 II. TANK ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. g 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM ;1/ C- El1 UNLEADED ❑ 2 LEADED [er3 DIESEL ❑3 CHEMICAL PRODUCT F14 OIL I PRODUCT ❑4 GASAHOL 1:15 JET FUEL ❑fi 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.N C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ I UBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 S NGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER UZI, STEELIIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑B 100%METHANOL COMPATI9LE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ C.INTERIOR 1 RUBBER UNED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 HENOLIC LINING LINING ❑ 5 GLASS UNING ❑6 UNLINED KNOWN IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES [-] NOoe HER 0.CORROSION ❑ 1 POLYETHI ENE WRAP ❑2 TAR OR ASPHALT - NYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION E:]91 NONE LK 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE AV 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 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 U 5 UNKNOWN A U 99 OTHER A U 1 STEELARON 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 A6 CONCRETE A U 7 STEEL CLAD WIFRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A 695 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. O� 5 1 VISUAL CII P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 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 1 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? DYES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION M AGENCY N FACILITY 10# TANK ID# El 11 lo lo I I 19 1 i-7T3T 1010 lo 124_ CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE U WITH AREA CODE fN F5T 6 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK s PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT O 6r,,J ,,12— M e(6-29•es) THIS.FORM MUST BE ACCOMPANI A FACILITYISITE APPLICATION, FORM 'A',UNLESS A CC7RRENT FORM`A' HAS BEEN FILED _� _ DATA PROCESSING COPY