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STATE OF CALIFORNIA* WATER RESOURCES CONTROLGRD{ FORM IB': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION 10 sL COMPLETE A SEPARATE FORM WITH THE FOLLOWI G INFORMATION FOR EACH TANK. a' _ Fo MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 10 ONE ITEM ❑ 7 PERMANENTLY CLOSED TANK ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: - I E. MQ/,7 N FARM TANK-YES❑ NO i (a 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN SO SPECIFY A. OWNERS TANK ID M (� r B. MANUFACTURED BY: w C. YEAR INSTALLED r/-74? D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A,1),IS NOT MARKED,COMPLETE ITEM DI A. [13 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM --JB C. ❑ i UNLEADED 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ! 1 PRODUCT ❑4 GA3AHOL ❑ 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.N C.A.S.q' III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,13,C,&D A.TYPE OF ❑ Iff DOUBLE WALLED E]3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ gg OTHER R. TANK I STEEUIRON E]2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CUD WIFIBERGLASS REINFORCED PLASTIC ❑ 5 CONCRETE MATERIAL ❑6 POLriINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBERLINED ❑2 ALKYD LINING ❑3 EPDXY LININGPHENOUIUNING W195 q LINING ❑ 5 GLASS LINING ❑6 UNLINED 95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE E995 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY 5 UNKNOWN A U 99 OTHER B. CONSTRUCTION SINGLE WALLED L DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A UR1 C. MATERIAL A U 5 ALUMINUM CONCRETE A U 7 STEEL CLAD W/FRP A U 9 GALVANIZED STEEL 5 UNKNOWN A U 8100%METHANOLCOMPATIBLE FRP A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. I t� P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 9 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TAN SUBSTANCE REMAINING IN K FILLED WITH GALLONS INERT MATERIAL? ❑YES ❑ NO 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 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID N z L � 3 CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME N PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT BY:A',UNLESS A CURRENT FOgM'q' HAS BEEN FILED FORMS(6.29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM ' /'