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STATE OF CALIFORNIA WATER RESOURCE,%.CONTROLBOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM = TANK TANK PERMIT APPLICATION INFORMATION % COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TAN . Z 10 „ MARK ONLk ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE Of INFORMATION Tf7 PERMANENTLY CLOSE K ONE ITEM �' ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8"TA Q W FACILITY/SITE NAME WHERETANK IS INSTALLED: /� " 6" f- Q�A e; FARM TANK-YES❑ NO (� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY C-TI W A. OWNERS TANK ID N Q B. MANUFACTURED BY: 4� C7) C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: O " IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOTMARKED, MPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑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 8 C.A.S.N C.A.S.N: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A TYPE OF ❑ 1 UEWuLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER I STEEL/NDN ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OIIiFA C. INTERIOR ❑ I RIBS LINED ❑2 ALKYDUNING ❑3 EPDXY LINING ❑ CLIC LINING LINING F-15 GLASS LINING ❑6 UNLINED UNKNOWN ❑ISUNNG MATERIAL COMPATIBLE NTH 100111 ETHANOLI ❑YES ❑NO ❑99 OTHER D. CORROSION ❑I POLYETHLENE WRAP ❑2 TAO OR ASPHALT ❑3RIIYLWRAP ❑4 RBERGLASSREINFORCEDPUSTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFO RMATI CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE U 9 OWN 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 A 95 UNK A U 99 OTHER I STEE A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM AU 6 N A U 7STEEL CLAD W/FRP A U B I00%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U NOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FO PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. S 1 VISUAL CHECK _P/B 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P B LE RONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 5 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE 8 VENO P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I ESTIMATED DATE LAST USED(MO/YRI 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN QLILLONB INERT MATERIAL? ❑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 A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID N 3 9 = I I I / 10 JY 17 1 10 1 D 1 v CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY: FORMB(6-29.8B) THIS FORM MUST BE ACCOMPANIEL cY A FACILITY/SITE APPLICATION, FORM A',UNLESS AT611RENT FORMW HASBEENFILED DATA PROCESSING COPY