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STATE OF CALIFORNIA WATER RESOURCES CONTR- BOARD " FORM B': UNDtAGROUND STORAGE TANK PRC GRAM "�' TANK / TANK PERMIT APPLICATION INFORMATION ('2% .o ✓COMPLETE A SEPARATE FORM WITH THE FOLLOWING INJBMMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEBFkNIV ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT /� 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED / FACILITY/SITE NAME WHERE TANK IS INSTALLED: �� 7 /C> �l.G 2P �55CO`F6171-) FARM TANK - YES Kr NO ❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN—SO SPECIFY A. OWNERS TANK IDX B. MANUFACTURED BY: V C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL C. YEAR INSTALLEDvx_ D. TANK CAPACITY IN GALLONS: U �� 11. TANK CONTENTS IF (A1)• IS MARKED. COMPLETE ITEM C. IF (A.11. IS NOT MARKED. COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM D. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑ 4 GASOHOL ❑ 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 & C.A.S. # C.A.S. p: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B• C• A D A TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER ❑ 95 UNKNOWN SYSTEM ❑ 2 SWGLEWAUED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER B. TANK ❑ 1 STEEL/IRON ❑ 2 STAINLESSSTEEL ❑ 3 FIBEAGUSS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL. ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100%METHANOL COMPATIBLE FRP A ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RIBBER U14ED ❑ 2 MKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLICUNING LINING F-15 GLASS LINING ❑ 6 UNLINED 8 100% METHANOL COMPATIBLE FRP ❑ 95 UNKNOWN ❑ ISLINING MATBBAL COMPATIBLE WITH 100%METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHttFNE WRAP - ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FlBFAGUSS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND. BOTH IFAPPLICABLF P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 3 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 9/ NONE P 8 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 - • wmrcc ICU vnucn rt NAL 1 Y Ur PbKUIHY AAIn Tn THc QPQT nr I" lunull 111, �-.RRECT. APPLICANT'S NAME (PRINTED A SIGNATURE) DATE COUNTY B A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U W OTHER O S U B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER C. MATERIAL A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE A U 91 NONE A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100% 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 OFTFrTInN SVSTEu MUST BE Ml- Sn P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 3 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 9/ NONE P 8 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 - • wmrcc ICU vnucn rt NAL 1 Y Ur PbKUIHY AAIn Tn THc QPQT nr I" lunull 111, �-.RRECT. APPLICANT'S NAME (PRINTED A SIGNATURE) DATE COUNTY B JURISDICTION N AGENCY B FACILITY ID 8 TANK ID B mT O S U -- / CURRENT LOCAL AGENCY FACLLITY ID a APPROVED BY NAME PHONE 4 WITH AREA CODE I PERMIT AMOUNT ORM B (8-29-88) THIS FORM MUST I E PERMIT APPROVAL DATE I PERMIT EXPIRATION DATE 7— RECEIPT 2 BY: v✓� - APPLICATION. FORM 'A'. UNLESS A cRMFNT FORM `I- NAA Rccu rn en DATA PROCESSING COPY Z IO