SITE INFORMATION AND CORRESPONDENCE

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' '.. ,WATER Pit STATE OF CALtFORNlA- ER RESOURCES CONTROL BOARD " - FORM 'B': �,� � � ' " �° UNDERGROUND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION p . ' TANK 'N COMPLETE A SEPARATE FORM WITH THE FOLLOIWING INFORMATION FOR EACH TANK. - z - MARK ONLY ❑ 1 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 FACILITY/SITE NAME WHERE TANK IS INSTALLED: v (/ . ` FARM TANK-YES❑ NO" .�► I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO s ECIFY '. A. OWNERS TANK 10 q B:MANUFACTURED BY: C.YEAR INSTALLED D. LANK CAPACITY IN GALLON ' If. TANK CONTENTS . " IF(kl),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL' ❑ 2 PETROLEUM B��PRODLIbf- E]4 C. A UNLEADED. " 2 LEADED_' ESEL_,3 CHEMICALPRODUCT ❑ 4 OILGASAHOL_ ',, c5 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 7 r,'t HAZARDOUS SUBSTANCE STORED&C.A.S.RI�� ] Ili. TANK CONSTRUCTION MARK ONE ITEM ONLY IN Box A,B.C,a D. . P A TYPE OF f-71I DOUBLE WALLED .' ❑3 SINGLE WALLED WITH EXTERIOR URER UN3fNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT" E]99 OTHER ' r .`. S%ELIIRON ❑2 STAINLESS STEEL ❑3 RBERGLASS ❑ 4 STEEL CLAD WlFlBEROLASS REINR)RCEO PLASPC x B.TANK , MATERIAL ❑5 CONCRETE 6 NYL'CHLORfDE' ❑7 ALUMINUM ❑ B 10RMETHANOLCOMPATIBLERTP .1 ❑9 BRONZE LVANIZED STEEL ❑95'UNKNOWN ` ❑99 OTHER r •. ❑ 1 2 LINING ❑3 EPO>t1 LINING ❑4 PHENOLICLlNING C-INRIOR t u NG ❑5 LI \ ❑6 UNLINED: . 4 UNKNOIVN + ' ll ❑ IS SING MATERIAL COMPATIBLE WITH 10096 METHANOL? ❑YES ❑NO ❑99 OTHER \N-' ' I .CORROSION ❑ I POLYETHLENEWAAP ❑2 TAR OR ASPHALT ❑3 VI P ❑ 4 FIBERGLASS REINFURCEDPLASRC PROTECTION ❑ 5 CATHODICPROTECTION ❑91 NONE UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A ' 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY " A U 91 NONE A U 95 UNKNOWN .A, if 99 OTHER,' � B.CONSTRUCTION, A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH -A U- 91 NONE, . A 5 UNKNOWN- A U 99 OTHER A U 1 STEEL/IRON < 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 U 6 CONCRETE A. U 7 STEEL CLADW/FRP,' A U"8 106%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A(1995'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 5 1 VISUALCHECK P 2 INVENTORY RECONCILIATION P B 3 VADOSE WELLS P 9 -4 ELECTRONIC MONITOR, P B 5 GROUND WATER MONITORING,WELLS t i�jvl. P S 5 PRECISION TESTING P S 7 PR€SSURETESTING P 8 91 NONE P S 95 UNKNOWN P 8 99 OTHER INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE.' L ESTIMATED DATE LAST7-ZE 2. ESTIMATED OUANTITY OF r •" 3.WAS TANK FILLED WITH !� ' SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO OALLONB -i THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT.':- APPLICANTS NAME(PRINTED E SIGNATURE) .. DATE _ y LOCAL 'AGENCY USE ONLY ` COUNTY A JURISDICTION N AGENCY II FACILITY SO#I TANK 1D N Ld ' C? - CURRENT LOCAL AGEN Y FACILITY ID!! - - APPROVED BY MIME - PHONE N WITH AREA CODE- - 22� PERMIT N MBER PERMIT APPROVAL DATE / PERM EXPIRATIONDATE x' _ - CHECK R PERMIT AMOUNT, SURCHARGE AMT. FEE CODE . , RECEIPT A.� ..1 _ - BY:- FOAM B(6-29-88) THIS FORM MUST BE ACCOMPANt 7 A FACILITYISITE APPLICATION, FORM W.UNLESS��'RENT FORM'A ,HAS BEEN FILED. LOCAL AGF_NCY COPY