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STATE OF CALIFORNIA' WATER RESOURCESCONTROI ')ARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWIN INFORMATION FOR EACH TANK. ,�� Z MARK ONLY ❑ I NEW PERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYCLO ONE ITEM F-1 PERMIT 2 INTERIM PERMIT ❑ 4 AMENDED 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED , N FACILITY/SITE NAME WHERE TANK IS INSTALLED: N/1eg2d<zo FARM TANK-YES❑ NO .A I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: Ile Iry C. YEARINSTALLED 6� D. TANK CAPACITY IN GALLONS'. OODIL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED OMPLETE ITEM D. 11 A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 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&CAS.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF ❑ I DOUWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINEN 95 UNKNOWN SYSTEM ❑2 LE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER E91 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CUD WIFIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B IOD%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C.INTERIOR Fl RUBBER LINED E]2 ALKYD LINING ❑ 3 EPDXY LINING ❑d OU LINING LINING F-15 GLASS LINING ❑6 UNLINED %UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH iDO%METHANOL? ❑YES : ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHIENEWRAP ❑2TAR OR ASPHALT VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODICPROTECTION ❑91 NONE %UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION AU 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLWINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A6 CONCRETE A U 7 STEELCLAD W}FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U %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. V S 1 VISUAL CHECK P Q2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 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 GALLONS 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 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID• TANK ID# 39 I p I 1� ? b6 CURRENT LOCAL AGENCY FACILITY ID k /- APPROVED BY NAME PHONE#WITH AREA CODE ,W-C 73 w ,Y 17 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE v ` CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORMB(6-29-8B) THIS FORM MUST BE ACCOMPANIE AFACILITY/SFTE APPLICATION, FORM 'A',UNLESS ALCRRENT FORMA' NASMMMFLEDD DATA PROCESSIMG COPY 12�