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STATE OF C,ALIFORNI . WATER RESOURCES CONTROL .. JARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANKTANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEWPERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION _ �_�7 PERMANENTLY CI NK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDE EMT 6 TEMPORARYTA KC OSURE 8 TANK REMOVE d e2- 'j4fv.4f- FACILITY/SITE NAME WHERE TANK IS INSTALLED: ©1` h G #1 V FARM TANK-YES X N ❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 7!;3 76 A. OWNERS TANK ID# B. MANUFACTURED BY: Q(,CJ n C YEAR INSTALLED a a x I S OF TANK CAPACITY IN GALLONS: 500 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL L.r 2 PETROLEUM B. C. 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ /OIL ❑ 1 PRODUCT /GASAHOL ❑ 5 JET FUEL ❑8 AVIATION GAS ❑ 5 HAZARDOUS 80 EMPTY [:] 95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN REM D,BELOW) II D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D n^ tm A. TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ®95 UNKNOWN NoV p ^ pAD SYSTEM E]2 SINGLE WALUD ❑4 SECONDARY CONTAINMENT ❑99 OTHER l E �f Lr TEEL CLAD BERGLASS B. TANK A CONCRETE ❑S POLYVINYL CHLORIDE ❑7 ALU NUM ❑B 590%MEMANOLICO PATIB COMPATIBLE IT�SERVINEs AL MATERIAL H ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR 1 RUBBER UNP ❑2 ALKYD LINING F-13 EPDXY LINING F-]4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑8 UNLINED EM 95 UNKNOWN ❑ ISLINING MATERIAL COMPATIAEWRH 100%METHANOL? ❑YES ❑ NO ❑ 99 QTHER D. CORROSION ❑ I PLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP, ❑ 4 RBERGLASS REINFORCED RASVC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE ^ U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 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 A40 95 UNKNOWN A U 99 OTHER A 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 U 5ALUMINUM A U 6CONCRETE A U 7STEEL CLAD W/FRP JA y 8100%METHANOLGOMPATIBLEFRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER _,.-. 14/L e- NXC N 171 p V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 8 #5UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED D'I IST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH GALLONS REMAINING IN INERT MATERIAL? E]YES [j NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE ORTE oS . f ll :zZZ8.7 LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# = .r- 7 y G 1 al I z CURRENT LOCAL AGENCY FACILT'IDID# APPROVED BY NAME PHONE#WITH AREA CODE m/�Z VV I�j PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERM IT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPAAIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA HAS BEEN FILED DATA PROCESSING COPY