SITE INFORMATION AND CORRESPONDENCE_CASE 2

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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'I3': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION m `A COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. as MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 ff RMANENTLY CLOSED TAWK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE Fle'TANK REMOVED G FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARMTANK-YES0 NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY ; A. OWNERS TANK ID# I . B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: - -7 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ ;.PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL F-13 CHEMICAL PRODUCT ' 4 OIL ❑ 1/PRODUCT ❑4 GASAHOL ❑5 FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS n 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.# G�P ��/ 'a C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF [::]/DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM 2 GLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER STEEL/IRON F-]2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC 8.TANK 1❑ MATERIAL5 CONCRETE ❑6 POLYVINYL CHLORIDE F-] 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FAP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR F__] 1 RUBBER LINED El ❑2 ALKYD LINING ❑3 EPDXY LINING 4 HENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED E7195.UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 99OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT n 3 'I&WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE LLj 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE dl A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE 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 WERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A k.6 CONCRETE A U 7 STEEL CLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 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. Ij S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 3 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 1'1 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 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? El YES ❑ 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# C lobills-13- Ig ] CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE 4 1/v�70 I PERINIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE I'.. CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE ECEIPT# B17 � So FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIff BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED LOC!l::":GE.'!CY COPY