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STATE OF CALIFORNIA* WATER RESOURCES CONTROL13OARD " FORM IBX: UNDERGROUND STORAGE TANK PROAM TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING I FORMATION FOR EACH TANK. Z 1O MARK ONLY -❑T NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY K ONE ITEM ❑2 INTERIM PERMIT ❑#AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMO L W _ FACILITY/SITE NAME WHERE TANK IS INSTALLED: 5-1 eT MAG UR FARM TANK-YES❑ NO IV 0 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# r7 IB. MANUFACTURED BY: C.YEAR INSTALLED G O. TANK CAPACITY IN GALLONS: (y IL TANK96NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A 1�11 MOTOR VEHICLE FUEL ❑2 PETROLEUM S. C. ❑ 1 UNLEADED ❑2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑#OILPflODl1CT ❑#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 6 CAS.F CA.S.M: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B.C,A D A TYPE OF ❑1 DOUBLEWNISI ❑3 SINGLE WALLED WITH EXTERIOR LINEA ❑95 UNKNOWN SYSTEM ❑2 SINGLE WAILED ❑t SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/MON ❑2 STAI7AESSSTEE ❑3 RBEASIASS ❑4 OR CLAD WIRBERGASS REINFORCED PLASTIC B.TANK ❑5 WNDiETE ❑6 POLYV MO LORDS ❑ 7 ALUMINUM ❑B 10A METHANOLCOMPATIBLF FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STS ❑95 UNKNOWN ❑99 OTHER ❑ I RUBBBHIIED ❑2 ALKYD LNNG ❑3 EPDXY LINING ❑A PNENOl1C UNING C.INTERIOR 5 GLASS IN ISFl 6 UNUNED ❑95 UNKNOWN LINING a ISUNNGMATEAWCOMpATI1oD%WnWa? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ I POLYETHBE Y1flAP ❑2 TAR OR ASRLLLT ❑3 VINYLWMP ❑1 FIBERGLASS RDNWRCFD RASTC PROTECTION ❑5 CATIDOC RgTECIION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE 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 L CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 UNEDTRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C,MATERIAL A U S ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U B IDD%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 S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S # ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS S 6 PRECISION TESTING P 9 7 PRESSURE TESTING P S 91 NONE P 9 95 UNKNOWN P 3 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MONA) 2 ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE RE"NING W INERT MATERIAL? [::]YES ❑NO 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 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY f - JURISDICTION• AGENCY 9 FACILITY ID# TANK ID 9 3 c� 6 CURRENT LOCAL AGENCY FACILITY 10 APPROVED BY NAME PHONE 9 WITH AREA CODE PERYIT NUM"A PERMIT APPROVAL DATE PERMIT EXPIRATION DATE g-/Z CHECK PERYR AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# EY: /K FORM B(6-29.811) THIS FORM MUST BE ACCOMPANIED BY A ACILRY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PRO ESSING COPY