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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD �•' FORM 'B': UNDERGROUND STORAGE TANK PROGRAM y TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWINGjNFORMATION FOR EACH TANK. ' MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ 7 PERMANENIL C D ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: O FARM TANK•YES 1 •Q I. TANK DESCRIPTION COMPLETE ALL ITEMS•IF UNKNOWN-30 SPECIFY A. OWNERS TANK IDI B. MANUFACTURED BY: W C.YEAR 1NST ED D. TANK CAPACITY IN GALLONS: 521& 11. TANK 96NTENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(A.1),JPS NOT MARKED,CqMPLETE ITEM D. CLT A. 01 MOTOR VEHICLE FUEL ❑2 PETROLEUMC. UNLEADED ❑2 LEADED ❑3 DIESEL B. ❑3 CHEMICAL PRODUCT ❑4 OIL I PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN REM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED h CALS.I CA.S.8: 111. TANK CONSTRUCTION NARK ONE ITEM ONLY IN BOX A B,C,A D A TYPE OF ❑ I DOLSLEWALLED ❑ 3 SINGLE WALLED NTH EKTEROR LINER ❑95 UNKNOWN SYSTEM ❑ 2 SNGUWAl1ED ❑4 SECONDARICOMAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 MEL CLAD W/FIBERGLASS REINFORCED PLASTIC B,TANK ❑5 CONCRETE ❑6 POLYVINYLOLORKIE ❑7 ALUMINUM ❑B 1009E METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C INTERIOR ❑ I RUBBER LINED ❑2 ALM LINING ❑3 EPOI(YUNING ❑4 PHENOLIC UNING LINING ❑5 GLASSUNING ❑6 UNUNED ❑95 UNKNOWN ❑ S LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYEIMENE WRAP ❑2 TARORASPHALT ❑3 VINriWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODICPROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. 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 1 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 STEELCLAD W/RLP A U 8 ROD%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 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 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 5 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED GATE LAST USED IMO/YR) 2.ESTIMATED QUANTITY OF - 3.WAS TANK FILLED WITH SUBSTANCE REMAINING INGALLONS INERT MATERIAL? ❑YES F-1 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 L LOCAL AGENCY USE ONLY COUNTY 8 JURISDICTION I AGENCY Y FACILITY IDX TANK 14 Y LlA CURRENT LOCAL AGENCY FACILITY 101 APPROVED BY NAME PHONE E WITH AREA COD 11 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE I CHECKS PERMIT AMOUNT . 'SURCHARGE AMT. FEE CODE ^'CEIPTI BY: /�� ✓✓\� FORM a(6.29.80) THIS FORM MUST BEACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED ATA PROCESSING COPY