SITE INFORMATION AND CORRESPONDENCE

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STATE OF CALIFORNIAi WATER RESOURCES CONTROL BOARD .��,o; .;, II 1. FORM 'B*: UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION . e . COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION I ONE ITEM ❑ ❑ 7 PERMANENTLYCLOS�ANK ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVED 1 FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TAMC•YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# i B. MANUFACTURED BY: ! C. YEAR INSTALLED p, TANK CAPACITY IN GALLONS: b II. TANK ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. F71 I MOTOR VEHICLE FUEL2 PETROLEUM E] B. C. 1;;��6NLEADEO ❑2 LEADED ❑3 DIESEL � ❑3 CHEMICAL PRODUCT ❑ 4 OIL I �pRODUCT ❑4 GASAHOL ❑5 JET FUEL [j6 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.k 1444 III. TANK CONSTRUCTION MART(ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF ❑ IDOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN E___I SYSTEM `SINGLE WALLED ❑4 SECONDARY,ICONTAINMENF El99 OTHER 1 STEEUIRON El STAINLESS STEEL .❑3 FIBERGLASS ❑,4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B. MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 1p0%METHANOLCOMPATIBLE fRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑2 ALKYD UN1NG ❑3 EPDXY LINING ❑4 PHENOLIC UNING LINING ❑ 5 GLASS LINING ❑'rUNUNED i ❑95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 900%METHANOL? ❑YES ❑NO � OTHER D.CORROSION ❑ 1 POLYETIiLENEWRAP 2 TAR OR ASPHALT 3 VINYLWRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE it95 UNKNOWN ❑99 OTHER s IV. PIPING INFORMATION CIRCLE A IFA E GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A( 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION AU 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH ' A U 91 NONE' A U 95 UNKNOWN A U 99 OTHER A U 1 S7EELlIRON A U 2 STAINLESS STEEL A U3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM AA6 CONCRETE A U 7 STEEL CLADW/FRP A U 6 100%METHANOL COMPATIBLE RP A U 9 GALVANIZED STEEL ACV 95 UNKNOWN A U 99 OTHER y V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. IV)r P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION {.P 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS N P S I PRECISION TESTING P 8 7 PRESSURE TESTING P 91 NONE P & 95 UNKNOWN' P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY�CLOSED IN PLACE - K 1.ESTIMAT DATE LAST USED MO/YR I ( 1 2. ESTIMA O QUANTITY OF 3. STANK FILLED WITH SU T E REMAINING IN Ff MATERIAL? ❑YES ❑NO GALLONS ' THIS FORM HAS BEEN COMPLETED UNDER PENALTY F PERJURY,AND TO TME BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT, '. ! APPLICANT'S NAME(PRINTED&SIGNATURE) 7E LOCAL AGENCY USE ONLY r COUNTY N JURISDICTION A AGENCY 8 FACILITY to N TANK ID N aF2 _1 - F-F1 D b 6L. 10 16 101-71 CURRENT LOCAL AG CY FA ITT ID @ /v A I APPRQV90 BY NAMEPHONE N WITH AREA CODE i PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE- 1' 4 CHECK M PERMIT AMOUNT CHARGE AMT. FEE CODE LRECET 11BY: FORMB(6-29-66) THIS FORM MUST BE ACCOMPANIED 611we'ACILITY/SITE APPLICATION, FORM `A',UNLESSANT FORMA' HAS BEEN FILED ►%ITA b^n/`rrw1R... y _ it