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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM Go TANK : • TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INF ATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑D RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIMPERMIT ❑ 1 AMENDEOPERMIT 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/BITE NAME WHERE TANK 18 INSTALLED: �O� Tic c�C S r�Y— FARM TANK-YES❑ NO ❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY A. OWNERS TANK IDN (� � B. MANUFACTURED BY: / C. YEAR INSTALLED a D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1).18 MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. A ❑ 1 MOTOR VEHICLE FUEL ❑2fpFIOLEUM B. UNLEADED 2 LEADED 0 DIESEL r-10 CHEMICAL PRODUCT OIL ElI I T /GA$AHOL 5 JET FUEL e AVIATION GAS ❑ 5 HAZARDOUS [:] 80 EMPTY E]95 UNKNOWN 2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 CA.S.I C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,A D A TYPE OF ❑ I WALLED ❑O SINGLE WALLED NTH EXTERIOR LINEA ❑95 UN(N01YN SYSTEM 2 SINGUEWALLED /SECONDAW COMAINMENT 99 OTHER El�l STEE om 2 STAINLESS STEEL ❑7 FIBERGLASS ❑/STEELCU)WIFIBEFIMASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑/POLYVNYL CFLOFOE ❑ 1 ALUMINUM ❑5 100%MET WIOL COMPATIBLE FRP MATERIAL ❑9 BRDNZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RABEAUNED ❑2 NING ❑0 EPDXY LINING ❑/PHENOWUNING LINING ❑ S MASS LINING UNUNED ❑95 UNKWM ❑ ISUMW MATERIAL WMPATIBLE NTH 100%METHANOLi ❑YES ❑ NO ❑ 99 OTHER F SION ❑ I POLYETIRENEDUMP 2 OR ASPHALT 2 YIN1l WRAP ❑/FIBERGLASS REINFORCED PLISTIC CTION ❑5 CATHDDC PROTECTION Lj 91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING IN FORMATIO ttjLFICLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE AU A U 2 PRESSURE W7=7= A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION AU I OLE WA U 2 DOUBLE WALLED A U 9 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 2 STAINLESSSTEEL A U S POLYVINYL CHLORIDE IPVC) A U / FIBERGLASS PIPE A U 91 NONE C.MATERIALA U 5 ALUMINUM A U 5 CONCRETE A U 7 STEELCLAD W/FRP A U B 1(X)%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 DETECTION SYSTEM MUST BE CIRCLED. P { I VISUAL CHECK P { 2INVENTORV RECONCILIATION ► t _ WENS P t / ELECTRONIC MONITOR P t 5 GROUND WATER MONITORING WELLS P t t PRECISION TESTING P t 7 PRESSURE TESTING P ;= NOAE P t 95 UNKNOWN P { 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE LAST USED(MO/YR) 2.ESIIMATED QUANTItt OF S.WAS TANK FILLED WITH ✓'L(L w�J c.lY` SUBSTANCE REMAINING IN INERT MATERIAL? �YES QNO GALLONS 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 SIGNAL URE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION{ AGENCY E FACILITY ID{ TANK ID E 3 q = 10 lo 17 10 lo lo CURRINpT LOCAL AGENCY EAGLET 10/ APPROVED BY NAME PHONE I WITH AREA CODE PlRY1T NUYtlR PERMIT APPROVAL DAT! PERYIT EXPIRATION DAT! CHECK/ PERYIT AMOUNT SURCHARGE AMT. FEE COD! ,RECEIPT I {Y; n \