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,,fcr^.,F,,. STATE OF CALIFORNIt WATER RESOURCES CONTRO/ 'OARD FORM `B': UNDERGROUND STORAGE TANK PROG�AM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE �ANK REMOVED 1511L FACILITY/SITE NAME WHERE TANK IS INSTALLED: Q Ce4ZhtP, FARM TANK - YES ❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN — SO SPECIFY A. OWNERS TANK IDB B. S. MANUFACTURED BY: C. YEAR INSTALLED PRODUCT D. TANK CAPACITY IN GALLONS: TANK CONTTENTS IF (A.11. IS MARKED. COMPLETE ITEM C. IF (A.11. IS NOT MARKED. COMPLETE ITEM o. r A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED LEADED ❑ 3 DIESEL F-13 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN REM D, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S. K C.A.S. M Ill. TANK CONSTRUCTION MARK ONE ITEM ONLk IN BOX A, B, C, S D A TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALO WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM [:]2 SNGLEWALLED ❑ 4 SECONDARY NTAINMENT ❑ 99 OTHER 2 PRESSURE F-11 STEEL/IRON ❑ 2 STAINLESS ❑ 3 RBERGLASS ❑ 4 STEEL CUD WIFIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑5 CONCRETE IDS POLYVINYLCHL IDE ❑ 7 ALUMINUM ❑ 6100% METHANOL COMPATIBLE FRP A U ❑ 9 BRONZE ❑ 10 GALVANIZED ❑ 95 UNKNOWN ❑ 99 OTHER ❑ i RUBBERUNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOUC LINING C. INTERIOR LINING ❑ 5 GLASS UNING ❑ 6 UNLINED ❑ 95 UNKNOWN A ❑ ISLINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2TAR OR ASPHALT 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVE GROUND, U I UNDERGROUND, BOTH IF APPLICABLE WAS TANK FILLED WITH CURRENTLOC AGENCY FACIA 1 SUBSTANCE REMAINING IN A SYSTEM TYPE A U i SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER PERMITAMOUNT B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOU81E WALLED 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 A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE U 7 STEELCLAD W/FRP A U 8 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A U 95 UNKNOWN U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOFkSECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE W S P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PkACE /. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF3. WAS TANK FILLED WITH CURRENTLOC AGENCY FACIA 1 SUBSTANCE REMAINING IN INERT MATERIAL? ❑ YES ❑ NO PHONE A WITH AREA CODE GALLONS THIS R RM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND O THE BEST OF MY KNOWLEDGE, IS TRUE AND C( APPLICANT'S NAME (PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY RRECT. COUNTY N JURISDICTION N AGENCY X FACILITY IDM TANK ID R CURRENTLOC AGENCY FACIA 1 APPROVED BY NAME a- - PHONE A WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK• PERMITAMOUNT SURCHARGE AMT. I FEE CODE RECEIPTR BY: -ORMB(6-29-08) THISFORMMUST FACILITY/SITE APPLICATION. FORM'A'.0KESSACDRRENT FORMA HASRFFNFILFe DATA PROCESSING COP' lo�