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STATE OF CALIFORNF WATER RESOURCESCONTRBOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM ' TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING ORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT Er5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO D TANK 10 ONE ITEM ❑ 2 INTERIM PERMIT ❑ 1 AMENDED PERMIT ❑8 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED G'r- FACILITY/SITE FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ No--Q Fv I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—80 SPECIFY A A. OWNERS TANK IDS 7 B. MANUFACTURED BY: to C. YEAR INSTALLED l D. TANK CAPACITY IN GALLONS: lGJ H. TANK F,2NTENTS IF(A1),18 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. Qi MOTOR VEHICLE FUEL ❑ 2 PETROLEUM C. ❑ I UNLEADED ❑2 LEADED SEL ❑3 CHEMICAL PRODUCT ❑ /OIL 6 1 PRODUCT ❑ /GASAHOL ❑5 JET FUEL ❑8 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 CAS.R C.A.S.I: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.8,C.S D A TYPE OF ❑ 1 WALLS) ❑3 SINGLE WALLED NTH EXTERIOR LINER ❑95 UNKNOWN SYSTEM Lff2 ❑ 1 SECONDARYCONTAINMENT ❑99 OTHER I STEELIMON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑/STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL ❑5 CONCRETE ❑8 POLYWNYLCHLORDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP ❑9 MDNZE ❑10 GALVAMZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ I R)BB LINED ❑2 LINING ❑3 EPDXY LINING ❑ 1 PHENOLIC UMNG C. INTERIOR LINING ❑5 GLA5$UMND 8 UNUNEO ❑95 UNKNOWN ❑B LINING MATERIAL COMPATIBLE WITH 10A METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑2 T ASPFMLT ❑3 OWL WRAP ❑1 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑S CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATIO E A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A — A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER S.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 11B UNKNOWN U 99 OTHER A U 1 STEELPRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U I FIBERGLASSPIPE A U 91 NONE C.MATERML A U 5 ALUMINUM A U B CONCRETE A U 7 STEEL CUD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 95 UNKN 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 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S / ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS t o PRECISION TESTING P B 7 PRESSURE TESTING P 6 91 NONE P K9SUNKNOW.. P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YRI 2. ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH GALLONS SUBSTANCE REMAINING IN 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY S JURISDICTION 1 AGENCY I FACILITY ID F TANK ID E = = L) C> / T n do CURRENT LOCAL AGENCY FACILITY IO 1 APPROVED BY NAME PHONE I WITH AREA CODE If PERMIT NUMBER PERMIT APPROVAL CA TL PERMIT EXPIRATION DATE CHECK PERMIT AMOUNT SURCHARGE AMT. FEECODE RECEIPTS 78 L'7/1� FORM 9(e 29.ee) THIS FORM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM W HAS BEEN FILED nATA DOnPCCCIMn PnDV