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STATE OF CALIFORk"~ WATER RESOURCES CONTK�,r11ARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK � TANK PERMIT APPLICATION INFORMATION ' COMPLETE A SEPARATE FORM WITH THE FOLLOWIN INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑A AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ®8 TANK REMOVE 0 FACILf7YYSITE NAME WHERE TANK IS INSTALLED: P o r t O f S t O C k t U n F U U d D i s t . FARM TANK-YES❑ 0E 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 1950 E . Miner A. OWNERS TANK IDX I B. MANUFACTURED By Unknown C. YEAR INSTALLED Unknown D. TANK CAPACITY IN GALLONS'. 11. TANK CONTENTS IF(At),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. A ® 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ®3 DIESEL ❑3 CHEMICAL PRODUCT ❑A OIL © 1 PRODUCT ❑ GASOHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑BO 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 d C A S.X C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B.C,S D A TYPE OF F-1I DOUBLE WALLED ❑3 SINGLE WALLED WITH DTEROR LINER ❑95 UNKNOWN SYSTEM ®2 SINGLE WALLED ❑A SECONDARY CON(AINMENT ❑99 OTHER ® 1 STEEL/IRON ❑2 SIMNLESS STEEL ❑3 FIBERGLASS ❑/STEEL CUD WIFIBERGUSS REINFORCED PLASTIC S.TANKEl5 CONCRETE E]6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑B 1W%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER UNED ❑2 ALM LINING ❑3 EPO(Y LINING ❑A PHENOLIC UNING C. INTERIOR LINING ❑5 GLASS LINING ©6 UNJNED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IDDM METH Wl ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POIYETHL NE WRAP ®2 TAR OR ASPHALT ❑3 WIRY WIMP ❑1 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑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 1 SUCTION A Y 2 PRESSURE A U 3 GRAVITY A U 9t NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A LA I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U % UNKNOWN A U 99 OTHER A(2)I STEEL/IRON A U 2STAWLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4FIBERI PIPE A U 91 NONE C.MATERML A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL GLAD W/FRP A V B 10011 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 F I VISUAL CHECK ( )S 2 INVENTORY RECONCILIATION ► S 3VADOSE WELLS P S A ELECTRONIC MONITOR P B 5 GROUNDWATER MONITORING WELLS P LT�6 PRECISION TESTING P E 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1 ESTIMATED DATE LAST USED(MO/YR) 2 ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN CALI INERT MATERIAL' E-]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 6 SIGNATURE( DATE Randy Thomas Q LOCAL AGENCY USE ONLY COUNTY X r JURISDICTION N AGENCY X FACILITY ID B TANK ID N CURRENT LOCAL AGENC cal IDX APPFIOVCD BY MAME N NE X WITH AMG CODE 0 � PERMIT NUMNR PERMIT APMOVAL DATE PERMIT QMIIATION DATE CME"E PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIIT X By //A --Z�* FORM B m-z9-ear TNM FORM MUST I E ACO'10 A=EY A FACamAmE AFFSICATIOK, FORM 'A',UFS'-- 5MMIR FDBM W FMS SEEN FILED/'//`/// N` 1 OMPA PROCESSING COPY 2 LOCAL AGENCYCtre 3 FILE COPY