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STATE OF CALIFORNIA* WATER RESOURCES CONTROL`ARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM a TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEDTAN ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT /❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED l3 FACILITY/SITE NAME WHERE TANK IS INSTALLED: p�/ E, �i7L �Li FARMTANK-YES❑ NO ANKwESGHIPIWN CUMPLLIEALLIIcma-Ir UNKN--' •••--••• A OWNERS TANK ID #C° U MAN�CAPACITY �GALLONS: C YEAR INSTALLED 19 1 D TANK PLETE ITEM C IF/All IS NOT MARKED, COMPLETE ITEM U. TANK CONTENTS IF (A.1), IS MARKED, COM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 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. # C.A.S. N: 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 UNER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER A ❑ 1 STEBUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK❑ 5� ❑ g POLYVINYL CHLORIDE ❑ 7 ALUMINUM F1B 108% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER U 3 POLYVINYL CHLORIDE (PVC) A U ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC UNING C. INTERIOR LINING ❑ 5 GLASS LINING F-16 UNLINED A ❑ 95 UNKNOWN B 100% METHANOL COMPATIBLE FRP ❑ 13 LINING MATERIAL COMPATIBLE WITH 109'b METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIB84GLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IVulennu ATlf%AI r,o A mnGnvCrmniimn U IF UNDERGROUND. BOTH IF APPLICABLE VI, A SYSTEM TYPE A U 1 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 A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U B 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER 1 CAI[ nCTCf_TInM RYSTFM rmm F P FOR PRIMARY. OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE UIHCLLU. P 8.1 VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSEWELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER pwI0^n"ATlnW nu TARIM' FFRMIANFNTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED (MOIVR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES GALLONS ❑ NO THIS FC""" ^ �"1O1='= I lnlncO OCAM I Tv nc PFR. 11 IRY ANLL I U IT -Ie 6tb I yr m r nlvvvvLcwc, - -- -•-• APPLICANT'S NAME (PRINTED 8 SIGNATURE) DATE me - O N N �l1 LVS.AL AUCNL I VAC VnLI COUNTY # JURISDICTION # II^A�IGENCYY # LTJ FACILITY IDR TANK ID # 10101013 CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NA PHONE p WITH AREA CODE Tpq PERMIT NUMBER PERMITAPPROVALDATE P RLIIT EXPIRATION DATE CHERMIT CKp PEAMOUNT 44 SURCHARGE AMT. FEE COD E RECEIPT# BY: w FORM B (6-29-86) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A', UNLESS XMIRRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY