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STATE OF CALIFORNIf WATER RESOURCES CONTRO' 'OARD FORM B': UNDERGROUND STORAGE TANK PRO 'AM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACFI TANK ofi MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYCLO " ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVED D 9 FACILITY/SITE NAME WHERE TANK IS INSTALLED:13�% �('� FARM TANK - YES 7 NO I� 1. TANK DESCRIPTION rnuPl PT, el. ITcuA_.c.,...ru, .... �.. es�...�.. A. OWNERS TANK ID N _ % B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS W (A.1), 15 MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. ❑ I DOUBLE WALLED C ❑ 1 UNLEADED LEADED ❑ 3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ BO EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME F HAZARDOUS SUBSTANCE STORED 8 C.A.S. R CAS. #: III. TANK CONSTRUCTION MARK ONE\ITEM ONLY IN BOX A, B, C, 8 D A. TYPE OF ❑ I DOUBLE WALLED ❑ 3INGLE WALLED WITH EXTERIOR LINER F-195 UNKNOWN SYSTEM ❑ 2 SINGLE WALLS) ❑ 4 ONDARY CONTAINMENT ❑ 99 OTHER ❑ I STEEL/IRON ❑ 2 STAI SS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 RxYVI LCHLOMDE ❑ 7 ALUMINUM ❑ 6100% METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVAN DSTEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RIBBER LINED ❑ 2ALKYD UNI❑ 3 EPDXY LINING ❑ 4 PHENOLIC UNING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNUNED ❑ 95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL. ❑ YES E]NO El99 OTHER D. CORROSION ❑ 1 POLYETHENEWRAP ❑ 2 TARORASPHALT❑ 3 VINYL WRAP ❑ 4 RBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 GATHODICPROTECRON ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U UNDERGROUND, BOTH IF APPLICABLE 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 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WAR LFD A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL 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 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FORS ONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S/ VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLA69 I. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED OUANTITY OF3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑ YES ❑ NO GALLONS THIS FE LOCAL AI RM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO Ll BEST OF MY KNOWLEDGE, IS TRUE AND C( APPLICANT'S NAME (PRINTED 8 SIGNATURE) DATE !cury unc nul v 7RECT. COUNTY N JURISDICTION R AGENCY # FACILITY ID 8 TANK ID # 161 (n 14 3 s CURRENT LOCALAGENCYFACILITY)*,* APPROVED BY NAM _ PHONE# WITH AREA CODE I PERMIT NUMBER I PERMIT APPROVAL DATE I PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE ANT. FEE CODE I RECEIPT # BY: ORM 8 f6-29-881 THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION . FORM 'A'. IINLFS�RFMT MMM Y' NAR RFFM FII FO 10