SITE INFORMATION AND CORRESPONDENCE

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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD 5`':�•—=sa' FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION m COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 1 Ci MARK ONLY r-11 NEW PERMIT F-13 RENEWAL PERMIT L�5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑8 TEMPORARY TANK CLOSURETANK REMOVED , 49 W w FACILITY/SITE NAME WHERE TANK IS INSTALLED: Cc— ( 12211 i1 L . OVA 11 t,, FARM TANK-YES❑ NO F"E' 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—$O SPECIFY A. OWNERSTANK ID O'4' ____ B. MAN61FACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: /000 0 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. w 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. G 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑4 OIL ® 1 PRODUCT I ❑ 4 GASAHOL ❑ 5 JET FUEL 6 AVIATION GAS 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.r3: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,AD A.TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ET95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEELIIRON ❑2 STAINLESS STEEL ❑ 3 FBERGLASS I ❑ 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK5 CONCRETE ❑6 POLYVINYLCHLORIDE 7 ALUMINUM F-18 t04%METHANOLCOM?ATIBLEFRP MATERIAL 9 BRONZE ❑ 10 GALVANIZED STEEL [2"95 UNKNOWN I ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING I ❑ 4 PHENOLIC LINING C. INTERIOR ❑ LINING NO 5 GLASS LINING ❑6 UNLINED 95 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑ 99 OTHER 0.CORROSION ❑ 1 POLYETHLENEWRAP 2 TAR OR ASPHALT 3 VINYLWRAP ❑ 4 RBERGLASSREINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE ' A.SYSTEM TYPE AM 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)l 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 NONF C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD WIFRP A U 8 100%METHANOL COMPATIBLE FRP . A U 9 GALVANIZEDSTEEL AUQ 95 UNKNOWN A U 99 OTHER DLEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONIDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. ' S 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P� S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITOMNG WELLS P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P; S 95 UNKNOWN P S 99 OTHER I VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) F2F. ESTIMATED QUANTITY OF I 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) I DATE LOCAL AGENCY USE ONLY i COUNTY# JURISDICTION# AGENCY# I FACILITY ID# TANK ID R F/Tq 1 (10 FLI lo IpT�:m , n _ CURRENT LOCAL AGENCY FACILITY ID Ik APPROVED 4Y NAM / - i --� PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK 8 PERMIT AMOUNT 8URCHARGE AMT. FEE COPE Rf�EIPT 0 PY momw FOAM B(8-29-88) THIS FORM MUST BE ACCOMPANIE,;el A FACILITY/SITE APPLICATION, FORM'A',UNLESS A CURRENT FORM IN HAS BEEN FILED FILE COPY y