SITE INFORMATION AND CORRESPONDENCE

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STATE OF CALIFORNIA`° WATER RESOU4CES CONFTRO"O-' ARD FORM `B': UNDERGROUND STORAGi TANK PROGRAM TANK TANK PERMIT APPLICATI6N INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOMNG INFORMATION FOR EACH TANK. � '' z I CJ MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 'CHANGE OF INFORMATION PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE Rn 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 0 5Wkty CX X03 FARM TANK-TES❑ NO 0/ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: C.YEAR INSTALLED 19j D. TANK CAPACITY IN GALLONS: iqO II. TANK 9ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A-1),IS NOT MARKED,COMPLETE ITEM D- A. Vf 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB/ C. ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL IPRODU T [:].4' GASAHOL ❑ S JET FUEL ❑ 6 AVIATION GAS Imo+ ❑ 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.# C.A.S,#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,8,C,a D A.TYK OF ❑ DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM R2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ki 1 STEELIIRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD WIFIBERGLASSREINFORCED PLASTIC 8.TANK ❑5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑d ENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED 95 UNKNOWN ❑ fSUNINGMATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES [:1110 ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TAR OR ASPHALT ❑ 3VINYLWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑ 91 NONE ;K UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGRC7UND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 RAVITY A U 91 NONE A 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 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAIN ESS STEEL A U 3 kLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE I I: C. MATERIAL A U S ALUMINUM A UA-CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A UNKNOWN A U 99 OTHER V. LEAK DETECTIO .SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 1 Ps 1 VISUAL CHECK L�S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS I P 8 6 PRECISION TESTING P S 7 PRESSURETESTWG P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PL ICE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY 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# JURISDICTION# AGENCY# FACILITY ID# TANK ID# j - CURRENT L CAL AGENCY �FjA/C'I�LITY IDN APPROVED BY NAME— PHONE N WITH AREA CODE .. PERMIT NUMBER__ PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECKN � PERMITIAMOONT CURCNARGEAMT. FE CODE 'FIBTNy Y. c3RM 6(6-29-88){THIS FOR16:WS!, %0MOIIED B A FACILITYISITE APPLICATION, Of�M `A',UNLESS A CU;;TRENT FORM`A' ENTM