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STATE OF CALIFORImiA WATER RESOURCES CONtffOL BOARD FORM B': UNDERGROUND STORAGE TANK PROGRAM TANK ''''` TANK PERMIT APPLICATION INFORMATION % COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED Q FACILITY/SITE NAME WHERE TANK III INSTALLED: v F, X7?Q/'�) FARM TANK•YES❑ NO i I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID e B. MANUFACTURED BY: C.YEAR INSTALLED 0. TANK CAPACITY IN GALLONS: 11. TANK CQNTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. (Etl MOTOR VEHICLE FUEL ❑2 PETROLEUM 6PRODLICT C. ❑ 1 UNLEADED LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑S HAZARDOUS ❑80 EMPTY 0 95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 C.A.S.a C.A.S.M: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.s.C.A D A.TYPE OF ❑ I�QLW WALLED ❑3 SINGLE WALLED MATH EXTERM LINER ❑95 UNK"m SYSTEM Ef sINOLE WALLED ❑4 SECONDARY CONTAN*V ❑99 OTHER ❑ I N ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WIFIBERMASS REINFORCED RASTIC B.TANK ❑ STEa/MIO5 CONCRETE ❑E POLYVIWLCHLOWDE 9951=m N ❑B IOD%METHANOLCOWPATtBLEFRP MATERIAL ❑9 BRONZE ❑ ID GALVANIZED STEELUNKNOWN ❑9s OTHER G INTERIOR ❑ I BU96ER u'a ❑2 ALKYD LWW ❑3 EPOI(Y LIN111G ❑4 UMNG LINING ❑5 MASS U NMIG ❑I UNLINED UNKNOWN ❑ IS U ANG MATERIAL COWPATIBLE WITH IOD%METMI4OL7 ❑YES ❑W ❑99 OTHER D.CORROSION ❑ I POLYETHLEWWRAP ❑2 TAR ORASPNALT ❑7 ❑4 FIBERGI.ASSREMIFOHC£DPLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NDNE 1M410401VN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND. U IF UNDERGROUND.BOTH IF APPLICABLE A.SYSTEM TYPE A ij.A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 1 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A e CONCRETE A U 7 STEEL CLAD W/FRP A U e 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 1U 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 • 1 YiSUAL CHECK P 2 INVENTORY RECONCILIATION P • 3 VADOSE WELLS P • 4 ELECTRONIC MONITOR P • 5 GROUND WATER MONITORING WELLS t 8 PRfCLSION TESTING P • 7 PRESSURE TESTING P • 91 NONE P • 95 UNKNOWN P 5 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE F77�__ TE LAST USED(MO(YR) 2.ESTIMATED OUANTITY OF I WAS TANK FILLED WITH SUBSTANCE REMAINING INGALLON• INERT MATERIAL7 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 LOCAL AGENCY USE ONLY COUNTY• JURISDICTION R AGENCY• FACILITY ID I TANK 10 t ME Ll --L] ' F7] I J D c)17/-I /-= CURRENT LOCAL AGENCY FACILITY ID 0 APPROVED•T NAME PHONE 9 WITH AREA CODE LCII"F*CK V P L_t L-/UM•ER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PERMIT AMOUNT 1URCHARGE AMT. FEE CODE °CEIPT/ eY: V^� FORM a(e-29-00) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION. FORM 'A'.timi m i ruaacNT mom w u as oeru fll-n