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STATE OF CALIFORNWATER RESOURCES CONTR(11'3OARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM Q TANK TANK PERMIT APPLICATION INF RMATIONCOMPLETE A SEPARATE FORM WITH THE FOLLOWING 1 ORMATION FOR EACH TANK.O Z MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT I � ❑ CHANGE OF 7 PERMANENTLY ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVE FACILITY/SITE NAME WHERE TANK IS INSTALLED:W FARM TANK -YES NO ❑ (V I. TANKDESCRIPTION COMPLETE ALL ITEMS -IF UNKNOWN—SO SPECIFYOO A. OWNERS TANK IDM B MANUFACTURED BY' v CJ C. YEARINSTALLED -_ D. TANK CAPACITY IN GALLONS 1 II. TANK ONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑ 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 STORED 8 C.A.S. M C.A.S. It III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN ROY A w A. TYPE OF ❑ OUBLE WALLED ❑ 3 SINGLE WALLED WITH EKIERIOR LINER ❑95 UNKNOWN SYSTEM SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER S TANK FYI 1 STEELPRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ q STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC . MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 100%METHANOLGOMPATIBLEFRP A ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR F-11 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 ENOLIC LINING LINING ❑ 5 GLASS UNING ❑ 6 UNLINED 8 100% METHANOL COMPATIBLE FRP 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IDA METHANOL? � YES NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHU NE WRAP 2 TAR OR ASPHALT 3 L WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRT11F AIC ARnvF ronnnin O o Iyj I P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS Or A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 95 UNKNOWN A U 99 OTHER INFORMATION ON TANK PERMANENTLY CLOSED IN PLA B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE U 95 UNKNOWN A U 99 OTHER FACILITY IDM A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 F ERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A110IN6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 5 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST RE niarl On Iyj I P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS Or ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S I NONE P S A UNKNOWN P S 99 OTHER INFORMATION ON TANK PERMANENTLY CLOSED IN PLA 101011-I'l-07pq 1010IC2111 I. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED GUANTITYOF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑ YES ❑ NO — FHIS F( HM nA5 OtLN CUMYLt I LU UNUEH PLIVAL / Y OF HEHJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND C( APPLICANT'S NAME (PRINTED 8 SIGNATURE) DATE RRECT. COUNTY K JURISDICTION # AGENCY M FACILITY ID K TANK ID # 101011-I'l-07pq 1010IC2111 CURRENT LyyO�^11^CAL AGENCY FACILITY IDM APPROVED BY NAME PHONE #WITH AREA CODE rlW� PERMIT NUMBER I PERMIT APPROVAL DATE I PERMIT EXPIRATION DATE ICHECK# I PERMIT AMOUNT =ORM B I6-29-881 THIS FORM MUST BE ACI SURCHARGE AMT. I FEE CODE DATA PROCESSING COPY RRE�EICEIPT# I BY:,WO �NRENT FORM W NAS BEEN FILED