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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. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 021's CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# 4 B. MANUFACTURED BY: Modesto we-1 / n C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: (JDO 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. W W A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ©3 CHEMICAL PRODUCT ❑ 4 OIL El 1 PRODUCT ❑ 4 GASAHOL 5 JET FUEL ❑6 AVIATION GAS WWW ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL [p-99 OTHER(DESCRIBE IN ITEM D,BELOW) D OF HAZARDOUS SUBSTANCE STORED&CA .Ip .S �/ ,S'/"OGi�e�GtT'�x SOlUC'YI I_,I. c.As.a: 80a j"/3 All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,ED A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WTTH EXTEROR UNER ❑95 UNKNOWN SYSTEM ©'FSINGLE WALLED ❑4 SECONDARYCONTMNMENT ❑ N OTHER �STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBERUNED ❑ 2 ALKYD LINING ❑3 EPDXY UNING ❑4 PHENOUC UNING LINING ❑5 GLASS UNING EJ<UNUNED ❑95 UNKNOWN ❑BUMNGMATERIALODMPATIBLEWRH100%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑��,I2(TARORASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION [ l NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH 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 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A1095 UNKNOWN A U 99 OTHER _ V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDAFIY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUAL CHECK ®8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MONFI) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH N/1 SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? [:]YES ❑ 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 LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 3 9101011111 :M1 1Sao i CURRENT LOCAL AGENCY FACILITY IG# APPROVED BY E PHONE#WITH AREA CODE -TN�f1/Y/� I £- PERMIT NUMBER PERMIT A"ROVAL DAW PERMIT EXPIRATION DATE ICHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT* BY: FORMB(3-7-8B) THIS FORM MUST BE ACCOMPAI'IB°!, BYA FACILITY/SITE APPLICATION, FORM 'A',UN RRENT FORMA HASBEENFILED DATA PROCESSING COPY