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_>•4•.. TRP°fe .. r��. .. ic.9,T•y� .q.. ��... -. ..rq �T. ..—e^�.... __.... ,. , •Ia:a STATE OF CALIFORNIr WATER RESOURCES CONTRC OARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION m COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. — T 3 RENEWAL PERMIT ❑ MARK ONLY RMI5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK 10 ❑ 1 NEW PE ❑ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED Gv FACILITY/SITE NAME WHERE TANK IS INSTALLED: /BOO JF/ LSD D FARM TANK-YES❑ NO N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK IDB V B. MANUFACTURED BY'. '/. 9 ' C. YEAR INSTALLED K. D. TANK CAPACITY IN GALLONS: ?/C?6 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(/A.1),IS NOT MARKED,COMPLETE ITEM D. A ❑3 CHEMICALHICLE PRODUCTL ❑4 OIL PETROLEUM I�f' PRODUCT C ❑ i UNLEADED 2 LEADED ❑3 DIESEL LLLIII ❑4 GABAHOI ❑ 5 JET FUEL ❑8 AVIATION GAB ❑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 8 C.A.S.B C.A.S.B: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,A D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3FIBERGLASS ❑ 4STEEL CLAD W/FSERGLSS REINFORCED PLASTIC ll B.TANK MATERIAL rLH ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE nyI�LUMINUM ❑8100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER ❑ I RUBBERUNED ❑2ALKYD LINING ❑3 EPDXYLINING 4KNOUCUNING C.`IN NRGOR ❑5 GLASS LINING ❑6 UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2TAR OR ASPHALT n 3)aWLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑ 91 NONE LZ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE AC -57 95 UNKNOWN A U 99 OTHER L CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A(yia5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U S ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A®P%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. P 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 6 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P)s 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH pY_ f"-r6-7((99!� GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? ES ❑ NO CC THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY X JURISDICTION B AGENCY B FACILITY ID B TANK ID B E I (oo 5 / 610101012- CURRENT 0 0 0 2.CURRENT LOCAL AGGENCY FACILITY ID X APPROVED BY NAME PHONE X WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ECK X PERMIT AMOUNT $URCIIARGE AMT. FEE CODE CEIPT X BY: CHG� FORM B(6-29-m) THIS FORM MUSTBE ACCOMPANIED AFACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORMA' HASBEENFILED DATA PROCESSING COPY