SITE INFORMATION AND CORRESPONDENCE

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STATE 'OF CALIFORNIAN WATERRESOURCES CONTROL BOARD FORM''B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION "COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑'1 NEW PERMIT ❑3-RENEWAL PERMITCHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2.INTERIM PERMIY ❑4 AMENDED PERMIT ❑fi TEMPORARY TANK CLOSURE' ❑8 TANK REMOVED j 6 . FACILITY/SITE NAME WHERE TANK IS INSTALLED: 17o650 FARM TANK-YES❑ NO .,.I. TANK DESCRIPTION COMPLETE ALL ITEMS,IF UNKNOWN—SO SPE FY A. OWNERS TANK ID# , U v : B. MANUFACTURED BY: Gc�r�C� C.YEAR INSTALLED - 0. TANK CAPACITY 1N GALLONS: Q II. TANK 92NTENTS IF(AL1),IIS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. 1 A: 1 MOTOR VEHICLE FUEL .❑ 2 PETROLEUM. B•' C. El 1 UNLEADED 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL i.PRODUCT. ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80.EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL' ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW► q. D. IF NOT MOTOR VE1 HCLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.$:N /�' C.A.S.k: Jr^ III.'TANK CONSTRUCTION.. MARK ONE ITEM ONLY IN BOX A.B,C.&D A TYPE OF ❑ i DOUBLE WALLED F-1'3 SINGLE WALLED WITH EXMRIOR UNER UNKNOWN - SYSTEM ❑2 SINGLEWALIID: ❑ SECONDAAYCONTAINMENT ❑ 99 OTHER ` ❑ 1 STEELlIRON ❑2 STAINLESS STEEL FIBERGLASS .. ❑4 STEEL CLAD WIfIBERGLASS REINFORCED PLASTIC: B.TANK ❑5 CONCRETE. RV7 dAINUM ❑ B 1D0%METHANOL COMPATIBLE FRP MATERAL, ❑9 6RDNZE �((❑ GALV5 UNKNOWN ❑99 OTHER ❑I RUBBERUNED 2 UNING1. 3 EPDXY LINING ❑4 PHENO INING ., C.INTERIOR ❑5 GLASS UNING ❑6 UNUNED UNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 10D%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION.' ❑ 1 POLYETHLENEWRAP E]2 TAR OR ASPHALT ❑3 VI ❑4 FlBERGLASS REINFORCED PLASTIC * PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE. UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE r , A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 95 UNKNOWN A U 99 OTHER 4 5 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 U 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 Ur 5 ALUMINUM A U 6 CONCRETE -. A 7 STEEL CLAD W/FRP '• A U 8 104%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A�9 OTHER vy+-h LEAK DETECTION SYSTEM 'CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. OP 6 1 VISUAL CHECK . ' P -S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY.CLOSED IN PLACE 1.ESTIMATED GATE LAST US€Q(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH, SUBSTANCE REMAINING,IN GALLONS INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,ANA TO THE-BEST OF MY KNOWLEDGE,!S TRUE AND CORRECT. i APPLICANT'S NAME(PRINTED a SIGNATURE) - DATE LOCAL AGENCY USE ONLY-- COUNTY N JURISDICTION R AGENCY M FACILITY Id R TANK ID N I J Eob I / ki I vl-e�; I dr-) lc)_W . -I F7 CURRENT LO AL AGENCY FACILITY ID R APPROVED Y KAME PHONE R WITH AREA CODE PERMITNUMBER - PERMIT APPROVAL OATS -PERMIT EAP RATION DATE '- CHECK R PERMIT AMOUNT SURCHARGE AMT. FEE CODE SCEIPT R BY: - - . . FORM 8(6-29-88) THIS FORM MUST BE ACCOMPANIEvBY A FACILITY/SITE APPLICATION, FORM`A',UNLESS A RRRENT FORM`AI HAS BEEN FILED