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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 FOLLOWIN2 INFORMATION FOR EACH TANK. _-. Z MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Eyf5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C}O/SEED TANK 10 ONE ITEM E]2 INTERIM PERMIT F-14 AMENDED PERMIT E] ! 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED , FACILITY/SITE NAME WHERE TANK IS INSTALLED: L I W 3 fit,✓ (�} FARM TANK-YES❑ NO � I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY Ca 00 A. OWNERS TANK ID# U B. MANUFACTURED BY: 1 CTI C. YEAR INSTALLEDLf I D. TANK CAPACITY IN GALLONS. 10,90 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 ❑ 2 �ROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED E]3 DIESEL ❑3 CHEMICAL PRODUCT [V4 OIL ❑ ODUCT ❑4 GASAHOL ❑5 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&C.A.S.# a oe U 1( C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF QA DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER F-1 95 UNKNOWN SYSTEM NGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/pON ❑2 STAINLESS STEEL ❑3 FIBERGLASS F-14 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR F-] I RUBBERUNED 2ALKYD LINING 3 EPDXY UNING ❑a>rHENOUC LINING LINING ❑ 5 GLASS UNING ❑ Egg fi UNLINED 95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES [:] NO [:]99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TARORASPHALT ❑ NYLWRAP ❑4 RBBTGLASSREINFORCEDPLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ryU1UV995 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 2 PRESSURE U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER 8.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 095 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A }L 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A kq 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION !STEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. NP VISUAL CHECK 3 2 INVENTOR RECONCILIATION P 8 3 VADOSE WELLS P 3 4 ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS P 6 PRECISION TESTING P S 7 PRESSURE TESTING P 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 GALLONS INERT MATERIAL? YES Ej 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 COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# Eul 100ioiS/ 0001 CURRENT LOCAL AGENCY FACILITY ID 0 APPROVED BY NAME PHONE#WITH AREA CODE 2/2/ f y G✓/ew PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE I RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANI YAFACILITY/SITE APPLICATION, FORM 'A',UNLESS-AC7JRRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY