SITE INFORMATION AND CORRESPONDENCE

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r $TAW PF-CALIFORNIA .. WATER RESOURCES CONTROL BOARD' "..'... FORM `B': UNDERGROUND STORAGE TANK PROGRAM �a TANK PERMIT APPLICATION INFORMATION TAN K .�. .. : .. COMPLETE A SEPARATE FOAM WITH THE FOLLOWING IN RMATION FOR EACH TANK. MARK ONLY •', -❑'1 NEW PERMIT ❑3 RENEWAL PERMIT' 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK pNE,ITEM. '``, E] 2 INTERIM PERMIT ❑ 4,AMENDED PERMIT. ❑6 TEMPORARY TANK CLOSURE ❑8'TANK REMOVED . FACILITY/SITE NAME WHERE TANK IS INSTALLED: (J n2(J FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECT -A. OWNERS TANK ID p - B. MANUFACTURED BY: - C, YEAR INS .TA (�/JL�L/ D. TANK CAPACITY IN GALLONS: `IL TANK CONTENTS IF(n 1!,IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A ❑'1 MOTOR VEHICLE FUEL ❑223P OLEUM B. G ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ! Dar PRODUCT OIL PRODUCT- ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ L-=.� ' ❑5 HAZARDOUS'• ❑80 EMPTY ❑95 UNKNOWN: ❑2 WASTE ❑7 METHANOL' ' ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF, ' HAZARDOUS SUBSTANCE STORED&C.A.S.p ' C.A.S.M III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,6 D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN 'srsTEa ❑2 SINGLE WAiiM ❑ss OTHER -.❑ 1 STEELIIRON. 3 LASS ❑4 STEEL CLAD WIRBFRGLASS REINFORCED PLASTIC &TANK ❑ 5 ODNCRETE ❑6 POLYVINYLCHLORIDE ❑7 AL M ❑ B 10096 METHANOL C06dPATIBLE FRP . .. MATERIAL ❑'9 BRONZE ❑ 10 GALVANIZED STEEL' UNKNOWN ❑99 OTHER 1 RUBBER UNtd1 2 ALKYD LINING - 3 EPDXY LINING 4 PHENO NING t '"�• C.INTERIOR ,>❑ ❑ _ � LINING 0 5 GLASS LINING ❑6 UNLINED UNKNOWN ❑IS UNING MATERIAL COMPATIBLE WITH 10096 METHANOL? ❑YES .❑NO ❑ 99 OTHER d,CORROSION ❑ I PMYEiHUM WRAP ❑2 TAR OR ASPHALT. ❑3 AWWRAP ❑4 FIBERGLASS REINFORCED PLASTIC red PROTECTION E]5.CATHODIC PROTECTION _]'91 NONE. UNKNOWN ❑ 99 OTHER I IV: PIPING INFORMATION CIRCLE A IFABOVE GROUND, U'IF UNDERGROUND,BOTH IF APPLICABLE ' A.SYSTEM TYPE - A U. 1 SUCTION ..A U'2 PRESSURE A U 3 GRAVITY A U 91 NONE A S UNKNOWN A U 99 OTHER i - B.CdNSTRUCTIdN A U 1 SINGLE WALLED- ..A U .2 DOUBLE WALLED A U 3 LINED TRENCH `• A U 91 NONE U 5 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 U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP ..A U 9 GALVANIZED STEEL A UNKNOWN A U 99 OTHER' V. LEAK DETECTION SYSTEM CIRCLE.P FOR PRIMARY,OR 5'FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. bq • P'$•1 VISUAL CHECK P S. 2 INVENTORY RECONCILIATION- P $ '3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P.S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 'S" 7 PRESSURE TESTING P J9 91 NONE P S 95 UNKNOWN P. S 99 OTHER _ VI, INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE T USED( !YR)- 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH 1.ESTIMATED DATE L_�s SUBSTANCE REMAINING IN - INERT MATERIAL?. ❑YES ❑ NO GALLONS i.. THIS FORM HAS BEEN COMPLETED�U.NDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. -7.APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE'ONLY COUNTY M JURISDICTIONS AGENCY S FACILITY IDB TANK ID 11 ° CURRENT LOCAL AGENCY FACILITY ID a« APPROVED 8Y NAME PHONE 0 WITH AREA CODE PERMIT NUMBER .' 1 [F�ERMIT APPROVAL DATE MIT�EXWRATIO DATE CHECK 0 PERMIT AMOUNT , SURCHARGE AMT. FEE GODS "GEIPT 9 BY: .,._ FORM I3(s-29 e3) THIS_FORNI MUST 13E ACCAMPANIE__A FACILITYISITE APPLICATION, FORM'A',UNLESS A'�iRENT FORMA' .HAS BEEN FILED