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STATE OF CALIFORK, WATER RESOURCES CONTRC JOARD FORM B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TAMIL MARKONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT G 6 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑A AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE r B TANK REMOVED q*f-- FACILITY/SITE NAME WHERE TANK IE INSTALLED: FARM TANK-YES[:] NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK IDM 1 B. MANUFACTURED BY n k n O W n C YEAR INSTALLED I I n k n n III I D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(All),19 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ® i MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C, ❑ 1 UNLEADED ❑2 LEADED ©3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑A OIL © 1 PRODUCT ❑A GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑BO 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 A C A .0 CA.S,A. 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,At D A TYPE OF ❑I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑%UNKNOWN SYSTEM ®2 SINGLE WALLED ❑A SECONDARY CONTAINMENT ❑99 OTHER ® I STEELIAON ❑2 STNNLESSSTEEL ❑3 FIBERGLASS ❑1 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED MEL ❑96 UNKNOWN ❑99 OTHER C.IMMRIOR ❑ I DUBBER LINED ❑2 AIKYDUNING ❑3 EPDXY LINING ❑1 NEMOUCUNING LINING ❑5 GLASS LINING ©6 UNLINED ❑95 UIK MOWN ❑IS LINING MATERIAL COMPATIBLE WITH 1006 METHANOL' ❑YES ❑NO ❑99 OTHER D.CORIIOSION ❑1 POLYER6ENE WRAP ©2 TAR OR ASPHALT ❑3 VIIW IP ❑1 FIBERGLASS REINFOHCFD PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑%UWNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U N UNKNOWN A U "OTHER B. CONSTRUCTION A I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U %UNKNOWN A U %OTHER AI STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(FVC) A U A FIBERGLASS PIPE A U 91 NONE C.MATERIAL A 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 6 IOD%METHANOL COMPATIBLEFRP A U 9 GALVANIZEDSTEEL A U M UNKNOWN A U MOTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST ME CIRCLED. • A ( VISUAL CHECK (1)S 2 INVENTORY RECONCILIATION P 1 3 VACOSE WELLS P 1 A ELECTRONIC MONITOR P 1 6 GROUND WATER MONITORING WELLS ©6 PRECISION TESTING P 6 7 PRESSURE TESTING P 1 91 NONE P 1 95 UNKNOWN P 1 "OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE t ESTIMATED DATE UST USED IMO/YRI 2 ESTIMATED QUANTITY OFOALLOM 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL' ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PE AL TY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) �,/ DATE Lance Ellis H60, 10-30-90 LOCAL AGENCY USE ONLY COUNTY 1 JURISDICTION• AOENCY I FACILITY ID• TANK ID I CURRENT LOCO AO[NCT EAGLET'IDA AMIIoKD 1Y NAYS PHONE 1 WITH ARIA Coot I'muff NUMBER PERMITAMIIOVALGATE PERM R EXI`MAT101A DATE CHECK t RIWR AMOUNT 1URCHA 101 AMT. FEE CODE MCEIR 1 BY: FORM816-n-MI THIS FOAM WATM*=WAMMD BY AFACBMMOMINKADDIL FORM'A',(BBEBBADUBert RDIM'A NABBEENRLED /L 1 DATA. OCESSING COPY 2 LOCAL AGENCY COP►.../3 Iii COPY