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STATE OF CALIFORK`,1 WATER RESOURCES CONTRCJOARD FORM B': UNDERGROUND STORAGE TANK PROGRAM r` TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT W 5 CHANGE OF INFORMATION ❑-- 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑A AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/81M NAME WHERE TANK 18 INSTALLED: Ellis Car Wash FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK IDN I B. MANUFACTURED BY: Unknown C. YEAR INSTALLED Unknown I D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(At).IS MARKED,COMPLETE ITEM C.IF(A1).IS NOT MARKED,COMPLETE ITEM D. A. ®1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. © I UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑A OIL I PRODUCT ❑A GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 90 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 6 C A .N CAS N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.S D A.TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EKT mm LINER ❑%UNKNOWN SYSTEM ©2 SINGLE WADED ❑A SECONDARY CONTAINMENT ❑M OTHER 0 I STEELIIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑1 STEEL OAD W/FIBERGLASS REINFORCED PLASTIC S.TANK ❑5 CONCRETE ❑6 POLYVWYLCHLORIDE ❑7 ALIANMN ❑8 IW%MMMOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ ID GALVANIZED STEEL ❑95 UNKNOWN ❑N OTHER ❑ C.INTERIOR RUBBER 1 U NED ❑2 AKYDLUNING E]3 EPDXY LINING E]A PHENOLIC UNING LINING ❑5 GLASS LINING ®6 UNLINED ❑%UMc140WN ❑ IS LINING MATERIAL COMPATIBLE WITH MIA METHANOL' ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ I POLYEMIERE WRAP ®2 TAR OR ASPHALT ❑3 VINY.WRAP ❑/FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑%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 PRESSURE A U 3 GRAVITY • U 91 NONE A U M UNKNOWN A U "OTHER B.CONSTRUCTION • t SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U % UNKNOWN • U 99 OTHER • U 1 STEELRRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE INC) A U A FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FAP A U 8 I ODM METHANOL COMPATIBLE FRP • U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR B FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P • t VISUAL CNECK P 2 INVENTORY RECONCILIATION P t 3 VADOSE WELLS P • 4 ELECTRONIC MONITOR P t 5 GROUND WATER MONITORING WELLS P • PRECISION TESTING P • 7 PRESSURE TESTING P t 91 NONE P • 95 UNKNOWN P • MOTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE t ESTIMATED DATE UST USED IMO/YR) 2. ESTIMATED OUANTITY OFGYLOW 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL' [—]YES [—] NO THIS FORM HAS BEEN COMPLETED UNDER PE ALTY OX PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(MINTED 6 SIGNATURE) � �� DATE Lance Ellis �C!/rP1- rlc�Q 10-30-90 LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY• FACILITY ID S TANK ID N I I I � CURRENT!U=%L AGENCY FACILITY ID A APPI1oY[D tY NAME PH"a F W I7H•R••CODB Elm 2— PEIIYR MIIMtEII PERMIT APMOVAL DATE PENN R EKPIILATHON DATE CHECK PERMIT AMOUNT •INICHAll"AMT. FEE CODE RECEIPTF W: FORMB(629-M) THISFOR11MINTEATSCOrAKED Br AFACBMOMAN IJUTION, FORM'A',WMADmiumor Now NYBEERYFEED 1 DATAAAAA�-AOCESSING COPY 2 LOCAL AGENCY OOPW,�,S RILE COPY