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STATE OF CALIFORNI.'' ` WATER'RPSOURCES CONTRA'' `OARD FORM `B': UND GROUND STORAGE TANK PRO AM TANK TANK PERMIT APPLICATION INFORMATION ° COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MAR NLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 0Nd-ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED =/5 S FACILITY/SITE NAME WHERE TANK IS INSTALLED: p2 Q�- EfOE T` L C-j—ELf FARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID q B. MANUFACTURED BY: (c,k C.YEAR INSTALLED 1170 D. TANK CAPACITY IN GALLONS: G W 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. N A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. UNLEADED ❑ 2 LEADED ❑ 3 DIESEL N ❑3 CHEMICAL PRODUCT ❑ 4 OIL I.v l ' PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM 0,BELOW) 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&CAS,It -' CA.S.q: x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,0,C,A D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM [�jI SINGLE WALLED ❑4 SECONDARY CONTArNMENF ❑99 OTHER l STEELIIRON ❑2 STAINLESS STEEL • E]_3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TMK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 1 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL 'C)95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC UNI NO C.INTERIOR 5 GLASS LINING 2'60 UNLINED 95 UNKNOWN LINING ❑ L ❑ ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES [:]No ❑99 OTHER D.CORROSION ❑ I POLYMRB E WRAP 2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODICPROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A 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(D 95 UNKNOWN A U 99 OTHER A U 1 STEELPRON 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 STEELCLADWIFRP - A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A©95 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 1 VISUAL CHECK O 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATE MONITORING WELLS S P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE' P 8 95 UNKNOWN P 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MOIYR) 2.ESTIMATED OUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑NO GALLONS 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 S JURISDICTION K AGENCY# V FACILITY 10'# TANK ID k ® 1 1 1 :1 1 1 ! 0 0101 / 1a1 / M CURRENT LOCAL AGENCY FACILITY ID i APPROVED BY NAW, PHONE N WITH AREA CODE ka C i EA Y- 17/1,5118-7 IpEfturrlkumsEa PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK i PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT i BY: FORM B(3.7-$B) THIS FORM MUST BE ACCOMPANIED i ACILITY/SITE APPLICATION, FORM `A',UNLESS A C FORMA' HAS BEEN FILED DATA PROCESSING COPY