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STATE OF CALIFORNIA WATER RESOURCES CON..,OL BOARD FORM 'B': C'I�NBERGROUND STORAGE TANK PROGRAM TANK > ' .TANK PERMIT APPLICATION INFORMATION ` Z++� COMPLETE A SEPARATE FORM WITH THE FOLLOWINGI I FORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ D RENEWAL PERMIT Ells-'CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEU_TAANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED fel FACILITY/SITE NAME WHERE TANK IS INSTALLED: 121,1 SP FARM TANK-YES❑ NO ❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK 10 N B. MANUFACTURED BY: (WC.— C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK ONTENTS IF(A-1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D: AFj I MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. ` 1 UNLEADED ❑ 2 LEADED ❑ 0 DIESEL ❑9 CHEMICAL.PRODUCT ❑ / OIL a 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ S AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 CA.S.N C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A. TYPE OF ❑ I DOUBLE WALLED ❑a SINGLE WALLED WITH EXTERIOR UNER ❑ 95 UNKNOWN SYSTEM E3 SINGLE WALLED ❑ 1 SECONDARY CONTAINMENT ❑ N OTHER I STEEL/IRON IRON ❑2 STAINLESS STEEL ❑0 FIBERGLASS ❑ a STEEL CUD WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑ MATERIAL 5 CONCRETE ❑ 6 POLYVINYLalORLOE ❑ 7 ALuMINUM ❑ a IW%METHANOLCOMPATIBUFRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL [-].95 UNKNOWN ❑ 99 OTHER ❑ G INTERIOR 1 RUBBER UNED ❑2 LINING ❑0 EPDXY UN 14G ❑ /PHENOUC LINING LINING ❑ 5 GLASSUMNG 6 UNLINED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER 0.CORROSION ❑ I POLYETHLENEWRAP 2 T ORASP}U ❑LT 0 VINYL WRAP ❑ 1 FIBERGLASS REINFORCED MASTIC PROTECTION ❑ 5 CATHOOICPROTECTION ❑ NONE ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I SU A U 2 PRESS A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A I SINOIE W ED A U 2 DOUBLE WALLED A U 9 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U A U 2 STAINLESS STEEL A U 9 POLYVINYL CHLORIDE(PVC) A U I FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U S CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONOAFTY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. Pi t VISUAL CHECK P 6 2 INVENTORY RECONCILIATION P i g VADOSE WELLS P S 4 ELECTRONIC MONITOR P i 5 GROUND WATER MONITORING WELLS P i 6 PRECISION TESTINO P i z PRESSURE TESTING P i 91 NONE P S 95 UNKNOWN P i 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF a.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY R(NOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED d SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID If TANK ID N G S CU o . CURRENT LOCAL AGENCY FACILITY ID 0 APPROVED BY NAME PHONE 0 WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK/ PERMIT AMOUNT SURCHARGE AMT. FEE COOS RECEIPT 1 5Y, cnnu A re-mmi THIA FIRM WIRT RF&rrnMDAWFn nv&c4ru rTviojyc and ipaysAu Clio u 'A9 uu,rook ,. ..,...,. .. ...