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STATE OF CALIFORNIA _ WATER RESOURCES CONTROL E ARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM COMPLETE 'a ` W Z TANK TANK PERMIT APPLICATION INFORMATION COA SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. "" 10 MARK ONLY ❑ I NEWPERMIT ❑ 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED Ca FACILITY/SITE NAME WHERE TANK IS INSTALLED: Inegg IF BaLe'tLA— FARM TANK-YES NO ❑ N fi I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY `/'��I`! OD A. OWNERS TANK ID N B. MANUFACTURED BY: s1, C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Qy v II. TANK ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,9OMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED [:] 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL (2WRASTE ODUCT E]4 GASAHOL E] 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑ ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.B C.A.S.It: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,6 D A TYPE OF42; E WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑ 95 UNKNOWN SYSTEM WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑6100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR F--] 1 RUBBER UNED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 P OLIO LINING LINING ❑5 GLASS LINING ❑6 UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 PoLYETHLENEWRAP ❑2 TAl10R ASPHALT n 3y 'L WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION [-]5 CATHODIC PROTECTION ❑91 NONE i��/95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKN -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 95 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERG PE A U 91 NONE C.MATERIAL A U 5 ALUMINUM AU A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 5 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 2 INVENTORY RECONI--IL'OPrION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 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 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY N FACILITY IDN TANK ID# Eo = = I I I Z& 1610 1 0 CURRENT LOCAL AGENCYLIiY IDN �i APPROVED BY NAME PHONE k WITH AREA CODE PERMIT NUMBER C/v�'Jfy/l PERMIT APPROVAL DATE PERMIT EXPIRATION DATE / CHECK k PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: WFORMS(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITEAPPLICATION, FORM'A,UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY