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STATE OF GALLFORNIA , -WATER RESOURCES CONTROL BOARD E. j ORM `B': UNDEROUND STORAGE TANK PRO AM .. :TANK•'PERMIT APPLICATION INFORMATION "'TANK.- COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. °G Ila I 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOS;;fol000 'I MARK ONLY ❑ ❑ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INS TALLED:,go2em c" FARM TANK-YE5 NO00 N 1. TANK DESCRIPTION COMPLETE"'ALL ITEMS-IF UNKNOWN—SO SPECIFY -cn T A, OWNERS TANK ID# MANUFACTURED BY: C) C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Q 11. TANK CONTENTS . IF(A.1),13 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM 0. i A. MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED VS LEADED ❑3 DIESEL t 3 CHEMICAL PRODUCT ❑4'01L i PRODUCT ❑4 GASAHOL JET FUEL ❑6 AVIA GAS e ❑ 5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN 92 WASTE ❑ 7 METHANOL .❑.99 OTHER(DESCRIBE IN rrEM D,BELOW D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF I HAZARDOUS SUBSTANCE STORED a CA.S,b CA.S.#: 111. TANK CONSTRUCTION MARK'!,ONE ITEM ONLY IN BOX A,B,C,AD —} A.TYPE OF L J OBLE WALLED ❑3 SINGLE WALLED WITH I7:1'ERIOR UNER ❑95 UNKNOWN SYSTEM 2 SfNGLEWALLED ❑4 SECONDARYCONTAINMB4T ❑99 OTHER ❑ 1 MEEUIRON.• ❑2 STAINLESS5fEEL 3 FIBERGLASS F-14 STEEL CLAD WIRBERGLASS REINFORCED PLASTIC ' B.TANK ❑ 5 CONCRETE. ❑6 POLYVINYL CHLORIDE ?ALUMINUM ❑8 108%MMIANOL COMPATIBLE RIP ' MATERIAL ❑9 BRONZE ❑10 GALVANIZED SIM ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER UNE] ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC UNING LINING ❑5 GLASS UNING ❑S UNLINED ❑95 UNKNOWN ❑ ISUNINGMATERIALCOMPATIBLEWrrH10D%METHANOL? ❑YES .❑NO ❑99 OTHER 0.CORROSION ❑ i POLYELASTICTHLENEWRAP ❑2 TARORASPIIALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED P I , PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE 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 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 FIBERGLASS PIPE A U 91 NONE C. MATERIAL :A U 5 ALUMINUM A U B CONCRETE A U 7 STEEL CLAD W/FRP A. U 8 100%METHANOL COMPATIBLE FHP A- U 9 GALVANIZED STEEL A U 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 P 8 2 INVENTORY RECONOUATION P S 3 VADOSE WEDS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 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 Y 1.ESTIMATED DATE LAST USED(MONS): - 2 ESTIMATED QUANTITY OF _ 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IM - MMION8 INERT MATERIAL? YE5., E NO . THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) -' _ DATE - - - LOCAL AGENCY USE ONLY i COUNTY N -JURISDICTION k AGENCY a>k FACILITY ID# TANK Ib N H T *� CURRENT LOCAL AGENCY FACILITY!D d.. _ APPROVED BY NAME .. PHONE N WITH AREA CO •^' PERMIT NUMBER -.g,$..:.. .• s PERMIT APPROVAL DATE PERMIT EXPIRATION DATE e f r CHECK N PERMIT AMOUNT CHARGE AMT _ FEE CODE � � R IPT 0 Y. FORM B(6-29-M THIS FORK 1 z FACILCfY/SFIE APPLICATION, FORM'A',UNLESS A C ifT FORM A- HAS BEAN FILED �ycrq? '"�*s ae DATA PROCESSING COPY l - �" T TIiiSFppY Ts, _ '.r Y I-294 }...._;d,�a�:�: