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STATE OF CALIFORNI(a WATER RESOURCES CONTROARD FORM 'B': UNDE GROUND STORAGE TANK PRO RAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. a Z MARK ONLY ❑ ❑ L..�'❑ 1 O 1 NEW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT E:] 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED CAL/ FACILITY/SITE NAME WHERE TANK IS INSTALLED: JO&C FARM TANK-YES❑ NOEj;. (� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A co A. OWNERS TANK ID# L B. MANUFACTURED BY: C. YEAR INSTALLED L)Ak, D. TANK CAPACITY IN GALLONS: QCJIII 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PET OLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL F-13 CHEMICAL PRODUCT OIL F-11 PRODUCT [:]4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑BO EMPTY ❑95 UNKNOWNASTE ❑7 METHANOL E jM-tTTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF �� C) HAZARDOUS SUBSTANCE STORED 8 C.A.S.q C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BO%A,B,C,&D A. TYPE OF ❑ 1 DOUBLEWALLED F—] 3 SINGLE WALLED WITH EI(TERIOR LINER ❑ 95 UNKNOWN SYSTEM INGLEWALLED ❑4 SECONDARY CONTAINMENT 99 OTHER 1 STEEUIRON ❑2 STAINLESS STEEL 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE F-� 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FOP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C, INTERIOR F-] 1 RUBBER UNED 2 ALKYD LINING 3 EPDXY LINING 4 PHEN LIC LINING LINING F-]5 GLASS LINING ❑ 6 UNLINED NKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH I!96 HANOL? ❑YES ❑ NO ❑ - D. CORROSION ❑ 1 POLYEfHLENE WRAP 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 IF ABOVE GROUND, U IF UNDER OUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER S.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH A U 9/ NONE A IU 6 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FISERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 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 695 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. 1 P 8 1 VISUAL CHECK P 6J 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS I8 6 PRECISION TESTING P S 7 PRESSURETESTING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER I. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED( [YR)/ 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH �}��/ SUBSTANCE REMAINING IN 13ALLON8 INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS dEEb 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# JURISDICTION# AGENCY# FACILITY ID# TANK ID# ENI = = I '1 6 g CURRENT LOCAL AOENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE •DAN 1 PERMIT NUMBER PERMIT APPROVAL DATE PER&iFrEXPIRATION D CXECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE I.RECEIPT# BY: FORM B(6-29-66) THIS FORM MUST BE ACCOMPAN199P.Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY