SITE INFORMATION AND CORRESPONDENCE

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STATE OF CALIFORM'1\ WATER RESOURCES CONTR' BOARD .••,�;, ., FORM 'B': P TANK PERMIT A DkAGROUND STORAGE TANK OGRAM PLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE;FOLLOWING;IINFORIiATTON FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF:INFORMATION ❑7 PERMARIDITLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT El6 n]APORARY'TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: r1 0 el (Ir M FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A_ OWNERS TANK ID B. MANUFACTURED ABY: 44-1 C. YEAR INSTALLED D. TANK CAPACITY In N GALLONS: ©'O t' It. TANK SONTENTS IF(A-1),IS(MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED jhh COMPLETE ITEM D. C A. Rl MOTOR VEHICLE FUEL ❑2 PETROLEUM $. C. ❑!1 UNLEAOEO 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT _❑ 4 OIL 1 PRODUCT ( ❑ih GASAHOL ❑5 TET RJf3 b AVIATION GAS i ❑5 HAZARDOUS ❑ 80 EMPTY [:] 95 UNKNOWN C]2 WASTE ❑ T METHANOL ❑99 OTHER(DESCRIBE iN ITEM 0,BELOW) 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.K /vA h C-A.S. xIII. TANK CONSTRUCTION MARK ONE ITEM ONLY 1N BOX A,B,C,&D A TYPE OF ❑ I OOUBLE WALLED ; ❑3 SINGLE WAUSD WITH EIQERICR UNs ❑95(NIRNOWN SYSTEMS rE�2 SINGLEWALLED ❑4 SECONDARY CONTAXIENT ❑99 m16 SIEEIJIRON ❑ IF 2 STAINLESS SIM �3 RBFRGLASS ❑4 STTCLADWIRBErAMSREINRIRCMRASTIC IL TANK(ARTERIAL ❑5 CONCRETE ❑fi POLYVINlLCHlORIDE ❑7 ALUMENU�i ❑8 100%0 COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER UNEP U'�S LINING ❑3 EPDXY UNING ❑4 PHB+�IOUC UNING I C INTERIOR R ❑ 5 GLASS UNING UNLINED Q 95 III ❑ ISURNGMATEAULCOAIPAnBLEwRH1o0%wHANOL? ❑YE5 ❑NO ❑99anHG t D.CORROSIONe's YETHLENEWRAP ❑2 TARORASPHALT ❑3 YIWLWRAP }❑4 RB�GIASSREINFORCEDRASTIC PROTECTION lC PROTECITON ❑91 NONE ❑95 UNKNOWN 99 OTHER ; IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF(APPLICABLE A. SYSTEM TYPE ACU) 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A u 99 OTHER IL CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH i' A 95 UNKNOWN A U 99 07140 a A U 1 STEELPRON A U 2 STAFNLESSSTEEL A U 3 POLYVINYLCHLORIDE(PVC) A U 4 FIBERGLASSPIPH .1 q C. MATERIAL A U 5 ALUMINUM A /U�6 CONCRETE A U 7 STEEL CLAD WIFRP A U 8 100%MErHANOL CCMPATIBLE FRP A U 9 GALVANIZED STEEL A N 95 UNKNOWN A U 99 OTHER r 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 - 0S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS S B PRECISION TESTING P S 7 PRESSURE T1 STING P S 91 NONE' P S 95 UNKNOWN P S 99 OTHER v VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE ESTIMATED DATE LAST USED(MO/YR) _ L ESTIMATED QUANTITY OF I 3.'NAS TANK FILLED WITH /{ SUBSTANCE REMAINING IN �� INERT MATERIAL? YES GALLONS ❑ 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 A SIGNATURE) DATE LOCAL AGENCY USE ONLY I iI COUNTY# JURISDICTION# AGENCY# FACILITY1p10 A TANK ID# 131 J CURRENT LOCAL AGENCY FACILITY ID APPROVED BY NMN PHONE II WITH AREA CODE PERMIT NUMBER Pf RMIT APPROVAL DATE PERMIT EmRATION DATE C/ i CHECK R PERMIT AMOUNT SURCHARGE AMT. FEE COOEjRECEIPT k BY: :j �, it I -- • FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIED-or A FACILfTY1STTE APPLICATION, FORM i}'A',UNLESS A Cv,aENT FORM`A' HAS BEEN FILED --- — DATA PROCESSING COPY -- °` k