SITE INFORMATION AND CORRESPONDENCE

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'--' STATE OF CALIFORN" WATER RESOURCES CONTR' ' BOARD ,,.. �• .; FORM B': 1 DERGROUND STORAGE TANK%,.OIOGRAM TANK TANK PERMIT APPLICATION INFORMATION I COMPLETE A SEPARATE FORM WITH THE FOLLOWINGINFORM"ATION FOR EACH TANK .�„;�r � I j MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF.3NFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑S TEMPORARY TANK CLOSURE ❑8 TANK REMOVED r FACILITY/SITE NAME WHERE TANK IS INSTALLED; 0 S j FARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK 10# a. B. MANUFACTURED lIBY: (� r C. YEAR INSTALLED0. TANK CAPACITY IN GALLONS: / 0 00 D I �• I II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,GCOMPLETE ITEM 0. A. MOTOR VEHICLE FUEL ❑ 2 PETROL.EQM B_.,_ / IC. ❑;i UNLEADED ❑2 LEADED 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL pR00UCT [:]:4' GASAHOL ❑5 jEr FUEL ❑ 6 AVIATION GAS y ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN 4❑�2 WASTE I ❑;7 METHANOL ❑49 OTHER(DESCRIBE IN ITEM D.BELOW) 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF �I HAZARDOUS SUBSTANCE STORED&C.A.S.# �/4 CAS.#- I ! Xll1. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,&D iI A TYPE OF ❑ I DOUBLE WALLS F-13 SINGLE WALLED WITH alEAlOR UNER ❑95 UNKNOWN SYSTEM M-l"SINGLEWAULED ❑4 SECONOARYCONTXWEiT ®99 OILIER 9E9.IOa0N ❑2 STAINLESS SITS ❑3 RBEROLASS ® 4 STEEL CLAD WIRBERGLASS REINFORCE PLASTIC , EL TANK MATERIAL 5 CONCRETE ❑S POLYYINYLCmRIDE ❑7 ALumNUAI ❑8 iw i�ImERiMIOLCOMPATImFRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UWNOWN ❑99 OTHER ❑ i RUBBER UNE ❑2 AWO LINING ❑3 EPDXY LINING a 4 PHBIOUC UNM C. INTERIOR >❑5 GLASSUNNG NE] a 95 UNXNONM ❑ IS UWW MATERIAL COMPATIBLE WITH 1004E WE3F WL? ❑YES ❑NO ❑99 0TF{ff4 D.CORROSION ❑ 1 YETHLENEWRAP ❑2 TAR ORASPNALT ❑3 VINYLWRAP ®4 RBCr'ILASSREWORC )PLASTIC PROTECTION CATHODICPROTECTION ❑91 NONE ❑95 UNKNOWN ®99 OIF!O IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND.8OTHIFaPIaLICABLE A SYSTEM TYPE A t&ol 1 SUC71ON A U 2 PRESSURE A U 3 GRAVITY, jI A U 99 OTHER -� B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 095 UNKNOWN A U 99 OTHER t A U 1 STEELPFION A U 2 STAINLESSSTEEL A U 3 POLYVINYLCHLORIDE(PVC) A U 4 F113EAGLASSPIPE C.MATERIAL A U5 ALUMINUM A U6 CONCRETE A U 7 STEEL CLAD WI FRF A U 8 100%METHANOLCOMPATIBLE FRP A U 9 GALVANIZED STEEL A fU 195 UNKNOWN A U 99 OTHERI 'I V hhh .il. ! V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LFAK DETECTION SYSTEM MUST BE CIRCLED. iF 1 VISUAL CHECK 0S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNO WATER MONITORING WELLS r/7 r P 5 PRECISION TESTING P S 7 PRESSURETEMNG P S 91 NONEP S 95 UNKNOWN P $ 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE e F 3. ESTIMATED DATE EAST USED(MO/YR) 2. ESTIMATED QUANTITY OF `I :I 3.WAS TANK RLLED WITH . INA I SUBSTANCE REMAINING IN I� I� INERT MATERIAL? YES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE ANO CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE( I I HATE LOCAL AGENCY USE ONLY ,� II COUNTY# JURISDICTION# AGENCY* FACILITY,]lD# TANK ID# D D l / td a171 ,� D 1 I Ll CURRENT LOCAL AGENCY FACILITY IO 4 APPROVED BY NAME '� PHONE N WITH AREA CODE ' OL g � PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXWPA7ION DATE :r CHECK N PERMIT AMOUNT SURCHARGE AMT FEE CODE RECEIPT# BY: F FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIED or A FACILTTYISiTE APPL1CATi0N, FORM i,`A',UNLESS At._:TENT FORIM`A• NAS BEEN FILED DATA PROCESSING COPY i