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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK, z MARK ONLY ❑ I NEWPERMIT ❑3 RENEWALPERMIT ❑`u CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 10 ONE ITEM 7] 2 INTERIM PERMIT ❑4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE ANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: �P�Ci55 �� , �I CI� m 11.e F[d ,_yT G✓1 FARM TANK-YES❑ NO ,jA, I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY CD A. OWNERS TANK ID N I B. MANUFACTURED BY: ( co C YEAR INSTALLED I 0. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A_ ❑ 1 MOTOR VEHICLE FUEL EE'2PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL Eel--PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ NI EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAMEOF ^ HAZARDOUS SUBSTANCE STORED&C.A.S.4 C.A.S.#: I✓ Il III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,&D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑1 STEEL/IRON ❑2 STAINLESS STEEL 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 10D%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED$TEFL ❑95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR 1 RUBBER LINED ❑2 ALKYD UNING ❑3 EPDXY LINING ❑4 PHENOUCUNING LINING ❑5 GLASS UNING UNLINED ❑95 UNKNOWN I,,,� A' / ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES F] NO Q 99 OTHER ✓�A` D. CORROSION ❑1 POLYETHLENE WRAP ❑1 TAR OR ASPHALT ❑3 VINYLWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE M 9S UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A CU 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 / STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A ®UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 6 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 5 6 PRECISION TESTING P 8 7 PRESSURE TESTING cp)s 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN OALLONB 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY z ISDICTI # AGENCY# FACILITY TOR TANKID# Oll E= I 0 I 0 I c) CURRENT LO GENCY FACILITY ID R APPRO D BY E PHONE R WITH AREA CODE LE f I I s CLQ PERMITNUMB PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERYR AMOU SURCHARGE AMT. FEE CODE I ^RCEIPT# BY: FORM B(6-29-88) THIS FORIMMUSTRACCGIMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A C RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY