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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - z 0 10 MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PEAMANENTLYC^SEDTANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDEOPERMIT ❑fi TEMPORARY TANK CLOSURE 8 TANK REMOVE // �^ �j F+ W FACILITY/SITE NAME WHERE TANK IS INSTALLED: CMl o l4V FARM TANK-YES❑ NO N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY N A. OWNERS TANK IDR B. MANUFACTURED BY: G(ivl N C. YEAR INSTALLEDZj�zD. TANK CAPACITY IN GALLONS: 3 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE IT D. A. Ffj�l MOTOR VEHICLE FUEL ❑ 2 PETROLEUM Fr7STE . ❑ 1 UNLEADED ❑ 2 LEADED DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL ❑4 GABAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑7 METHANOL ❑1)9 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.R /V C.A.S.R: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A. TYPE OF DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. MATERIAL TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 18 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑p2UKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC UNING LINING ❑5 GLASS LINING 6 UNLINED ❑95 OKNOWN ❑ IS LINING MATERIAL COMPATIBLE WRH 10(Wo METHANOL? ❑YES ❑NO 99 OTHER D. CORROSION ❑ 1 POLYETHLENEWMP 2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFA BOVE 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 S.CONSTRUCTION A Wl 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 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A /U1T' 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A(l 9 GALVANIZED STEEL A U 95 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. 11 P 8 1VISUAL CHECK P S 2 INVENTORY RECONCILIATION P E 3VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ESTIMA ED DATE LAST USED(MO/YR) 2. ESTIMATED DLA TITY OF 3. WAST NK FILLED WITH - / SUBSTANCE Fid !y 1NG IN 10/9 �jE{T� ERIAL? ❑YES ❑ NO �l/ JV GALLONS N THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. I APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION! AGENCY! FACILITY IDR TANKID# 3 ` = = 1 6 10 1 / = 1 DU 162 17 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE M WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATON DATE CHECK! PERMIT AMOUNT SURCHARGE AMT. FEECODE RECEIPT! BY: C' FORM B(6 29 9e) THIS FORM MUST BE ACCOMPANIEIY .A FAbCITY/SITE APPLICATION, FORM `A',UNLESS A LZ4RENf-f'0RMS BEEN FILED