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STATE OF CALIFOR WATER RESOURCES CONT BOARD FORM `B': UND RGROUND STORAGE TANK PRGRAM A' TANK PERMIT APPLICATION INFORMATION x m; TANK �.: COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMITDIS CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 1 rJ FACILITY/SITE NAME WHERE TANK IS INSTALLED: C) �trCjLtynFARM TANK-YES[::] NO I(Q I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# f B. MANUFACTURED BY: ic, 3 C. YEAR INSTALLED '�?� D. TANK CAPACITY IN GALLONS, % GUo Il. TANK C TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. AE]jI'MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ I UNLEADED ❑ 2 LEADED 3 DIESEL El CHEMICAL PRODUCT ❑ 4 OIL F' PR6DUCT ❑ 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&C.A.S.# &� x C,A.S-#: ju xlll. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN. SYSTEM LalSINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER STEEL/IRON ❑ 2 STAINLESS STEEL F-13 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM E] 8 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ IO GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER ❑ i RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENO LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑6 UNLINED UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION [:] 5 CATHOOIC PROTECTION ❑ 91 NONE LNKNOWN ❑N 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 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 5 UNKNOWN ~A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 6 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 61 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 S I VISUAL CHECK Or. 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH GALLONS ❑YE5 SUBSTANCE REMAINING IN INERT MATERIAL? ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# = I I I I Ll 1-1 LdollloEg a 1 CURRENT LOCAL AGENCY FACILITY IDN APPROVED By NAME PHONE N WITH AREA CODE �C PERMIT NUMBER PERMIT APPROVAATE PERMIT EXF69ATION DATE GWECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: ldwL RMB(3-7-88) THIS FORM MUST BE ACCOMPANIL'M A FACILITYISITE APPLICATION, FORM `A',UNLESS A - RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY