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STATE OF CALIFORNI WATER RESOURCES CONTRC iOARD FORM 'B': UNDERGROUND STORAGE TANK PROZ;RAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT I FACILITY/SITE NAME WHERE TANK IS INSTALLED: J3 / ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY TANK CLOSURE I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN — SO SPECIFY ❑ 7 P MANENTLY CLgZU 8 TANK REMOVED U —D I/ FARM TANK-YESI I NO A. OWNERS TA NK IO# B B. MANUFACTURED BY: ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL DUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS C. YEARINSTALLED ❑ 2 WASTE D. TANK CAPACITY IN GALLONS' D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF HAZARDOUS SUBSTANCE TORED 8 C.A.S. # C.A.S. #: D II. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1). IS NOT MARKED. OGMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B C. 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL DUCT ❑ 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 TORED 8 C.A.S. # C.A.S. #: III. TANK CONSTRUCTIC* MARK ONE ITEM ONLY IN BOX A, B, C, 6 D A. TYPE OF ❑ 1 DOUBLE WAL D F73 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SNGLEWAUF ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 UEELARON ❑ 2 STAINLESS MEL ❑ 3 FIBERGLASS ❑ 4 STEEL QAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ B 1DD%METHANOLOOMPATIBLEFRP ❑ 9 BRONZE ❑ 10 GALVANIZEDETEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING 6 UNUNED PERMIT NUMBER ❑ 95 UNKNOWN ❑ IS UNING MATERIAL COMPATIB WITH100%METHANOL7 ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAPTAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FlBRiGLASS REINFORCED PLASTIC PROTECTION [:]5 CATHODIC PROTECTION ❑ 9 E ❑ 95 UNKNOWN 1-1 99 OTHER IV. PIPING INFORMATION CIRCLE A IFAS VEGROUND, U IF UNDERGROUND, BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 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 OUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U2 5 INLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U B CO CRETE A U 7 STEEL CLAD W/RTP A U 8 IOD% METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A U 95 UN OWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FORPRIMA ,ORS FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 6 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P 8 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 A NONE P S 95 UNKNOWN P 9 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOS D IN PLACE 1. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED OU TITY OF 3. WAS TANK FILLED WITH TANK ID # SUBSTANCE REM INING IN INERT MATERIAL? ❑ YES [:]NO GALLONS THIS F( LU4 Mll- RM HAS BEEN COMPLETED UNDER PENALTY OF PERJU , AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND C( APPLICANT'S NAME (PRINTED A SIGNATURE) DATE 7RECT. COUNTY # JURISDICTION # AGENCY # FACILITY ID # TANK ID # === 10 10135 003 CURRENT LOCAL AGENCY FA ILL IDN APPROVED BY NAME p /�y� PHONE # WITH AREA CODE c 3 a - PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK M PERMIT AMOUNTI SURCHARGE AMT. FEE CODE RECEIPT* BY: ORM B (6 -29 -ss) THIS FORM MUST SE A FACILITY/SITE APPLICATION. DATA PROCESSING COs FORM'A' HAS RFFN RI FO 10 N to W