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fyOUMCtS STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD W °o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B -see , o 1 Cil lipll N� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 711 NEW PERMIT F73 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM __1 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED pq 4 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: COUNTY OF SAN JOAQUIN -- JAIL/HONOR FARM I3/g I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# 2374 S. MANUFACTURED BY: UNKNOWN C. DATE INSTALLED(MO/DAYNEAR) 1976 D. TANK CAPACITY IN GALLONS: 12,000 { il.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A1� 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C 1a REGULAR UNLEADED O 3 DIESEL ❑ 6 AVIATION GAS f ❑ 2 PETROLEUM ❑ 80 EMPTY ® 1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ lc MIDGRADE UNLEADED 5 JET FUEL 0 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL F*1 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC I MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED )ql 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP Lj 4 FIBERGLASS REINFORCED PLASTIC '' CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BtC. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER Ii B. CONSTRUCTION A V 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C C. MATERIAL AND A(D 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION E 1 MECHANICAL LINE LEAK [::]2 LINE TIGHTNESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC LINE [::]5 AUTOMATIC PUMP ❑ 99 OTHER DETECTOR TESTING MONITORING LEAK DETECTOR SHUTDOWN V.TANK LEAK DETECTION �' ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATIONORY ❑ 3 VADOZEMONITORING ❑ 4 AUTOMATGAUGNGIC TANK ❑ 5 GROUND MONITORING TESTING 6 ANNUALTESTINGTANK ❑ 7 CONTINUOUS INTERSTITIAL ❑ 8 SIR ❑TORING g WEEKLY GAUGANGAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) i 1.ESTIMATED DA1TISED(MO/DAY/YR) 2 SUBSTANCE REMAININGESTIMATED QUANTITY GALLONS 3 WASNERT MATERIALTANK FILLED ? YES EK] i THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE fff (PRINTED S SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# I STATE I.D.# m PERMIT NUMBER PERMIT APPROVED BY/DATE P MIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT ICATION'FORM A,UNLESS A CURRENT FORM A HAS BEEN FILgLFORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A N. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENT[ UNDERGROUND STORAGE TANK REGULATIONS FORM B (6-95)