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STATE OF CALIFORA WATER RESOURC FORM 'B': UNDERGROUND STORAGE G;Ite 96465B .� r TANK TANK PERMIT APPLICATION INFORMAII-PON9 ' CO PLETE A SEPARATE FORM WITH THE FOLLOW I Q _ MARK ONLY Ell NEW PERMIT In RENEWAL PERMIT ❑5 CHIMBB61FMlFDRPSTRVICE 7 PERMANENTLY CLOSED TANK ONE ITEM F-12 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: i (:)17� PeTShm 'P n FARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID N WC7706CB. MANUFACTURED BY: OWDT C.YEAR INSTALLED 1988 D. TANK CAPACITY IN GALLONS: 10,000 alIDns 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE REM C.IF(A1),IS NOT MARKED,COMPLETE ITEM O. A, ® 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ® 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICALPRODUCT ❑4 OIL JEX 1 PRODUCT ❑4 GASAHOL ❑5 JET NEL ❑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.R D.A.B.R: 8006619 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN SOK A B,C,A D A TYPE OF Q I DGUBLEwALLEO ❑3 SINGLE WALLED WITH EKTB6GR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑1 STEEUIRON ❑2 STAINLESSSTEEL a FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCREIE ❑6 POLYVINYLCHLORIDE E]7 ALUMINUM ❑8100AMETHANOLCOMPATIBLEFRP MATERIAL ❑9 BRONZE ❑ 18 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑1 RUBBER UNED ❑2 ALKYD UNING ❑3 EPDXY UNING ❑A PHENOLIC UNING C.INTERIOR N RI R ®5 GLASS UNING ❑6 UNLINED ❑95 UNKNOWN ❑ IS UNIW MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER 0.CORROSION ❑1 POLYETHLENE WRAP ❑2 TAN OR ASPHALT ❑3 VIWL WRAP ❑4 RBERGUSSREINTORCEDPUSOC PROTECTION ❑5 CATHODIC PROTECTION ❑X 91 NONE ❑%UNKNOWN ❑%OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF 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 I SINGLE WALLED A @ 2 DOUBLE 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 04 FISERGLASSPIPE 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 U MOTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1VISUAL CHECK P 2 INVENTORY RECONCILIATION P 6 3VADOSE WELLS O6 4 ELECTRONIC MONITOR P 6 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 6 7 PRESSURETESTING P S 91 NONE P 6 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OOANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PEN TY OF P URY A TO T E F MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE XbV�NSon� Ll- 3() -g, LOCAL AGENCY USE ONLY COUNTY R JURISDICTION W AGENCY P FACILITY ID W TANK ID R ail CURRENT LOCK AGENCY FACILITY IDI APPROVED BY NAME PHONE 0 WITH AREA CODE PERMIT NUMWX PERMIT APPROVAL DATE PERMIT EXPIRATION DATE I.. CXECK 1 PERYIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT E BY: - FORMB(629-m) THIS FORM MUST SEACWI 'AFACLRYHREAPHICATIOK, FORM'A" FONR IMS BEEN FILED 1 DAT CESSING COPY 2 LOCAL AGENCY FSl COPY