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STATE OF CALIFORK, WATER RESOURCES CONTR(JOARD FORM B': UNDERGROUND STORAGE TANK PROGRAM = TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EAC"TANK _ MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑N AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 7-'B TANK REMOVED 9 FACILITY/SITE NAME WHERE TANK IS INSTALLED'. Ellis C a r Wash FARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—BO SPECIFY A. OWNERS TANK IDN 1 B. MANUFACTURED BY: Unknown C. YEAR INSTALLED Unknown I D. TANK CAPACITY IN GALLONS: 5000 11. TANK CONTENTS IF(AA),IS MARKED,COMPLETE FTEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ® I MOTOR VEHICLE FUEL ❑2 PETROLEUM To C. © 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑A OIL PRODUCT ❑N GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ED EMPTY ❑95 UNKNOWNWASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 C.A.S.A C.A.S.M: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑%UNKNOWN SYSTEM ®2 SINGLE WALLED ❑1 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEUIRON ❑2 STAINLESS STEEL ❑3 RBEAGASS ❑/STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑B 1W%METHANOL COMPATIBLE RN MATERIA ❑9 BION2E ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ I RIBBER UNED ❑2 ALKYD UNING ❑3 EPDXY UNNG ❑K PHENOUC UMNG C.LININRGIOR ❑5 GLASS LINKX❑6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IBO%METHAHOLY ❑YES ❑NO ❑99 OTHER D.CORROSION ❑1 POLYMUNE WRAP ❑2 TAA OR ASPHALT ❑3 WNYL WRAP ❑1 RBEAGUSS REINFORCED RASH 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 A U I SUCTION A 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U %UNKNOWN A U N OTHER S.CONSTRUCTION A U I 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)I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U A FISERGLASSPIPE A U 91 NONE C.MATERIAL A U 5ALUMINUM A U 6CONCRETE A U 7STEEL CLAD W/FRP A U 61D911METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U N OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. • % 1 VISUALCHECK • 2 INVENTORY RECONCILIATION F S 3 VADOSE WELLS P S A ELECTRONIC MO NROR P S 5 GROUND WATER MONITORING WELLS • PRECISION TES TING P f 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I ESTIMATED DATE LAST USED(MO/YR) 2 ESTIMATED OUANTITY OF 3. WAS TANK FILLED WITH GALLONS REMAINING IN INERT MATERIAL? ❑YES [:]NO THIS FORM HAS BEEN COMPLETED UNDER= LTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT. APPLICANT'S NAME IPRINTED 6 SIGNATURE ""'""'" DATE Lance Ellis Wywn— HC' 10-30-90 LOCAL AGENCY USE ONLY COUNTY S JURISDICTION N AGENCY P FACILITY ID E TANK ID 4 cuRRcrrr LOCILL AGE Ncr PACIIM ID• AlIWAOWED EY NAME ~ME P WITH AREA Co" G �Z PUMIT NUYS[R PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK PERMIT AMOUNT SURCHARGE AMT. RECODE RECEIPT. BY: FORMA 1629-M) THIS FORM MUST BE ACCOWAMM BY A FACBTIY7MR APRMTIDK FORM'A',LW MACUWM FDmi'A' IMSBEENFILED 1 OATA-..IOCESSING COPY 2 LOCAL AGENCY COP►. RLE COPY