SITE INFORMATION AND CORRESPONDENCE

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.., �.-�"�s'"a�"- J`rrx'i• .,..+:.,: "1177117— �•'►..s�..,� � ir'��yy°*'�a r��*r+.lr�,:^r.k ., ,.�,,.�; 7 � a ,a ( / I STATE OF CALIFORNIA ! WATER RESOURCES CONTROL BOARD s• FORM `B': UNDERGROUND STORAGE TANK PROGRAM Y �� TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Flip- z 1Q MARK ONLY ❑ 1 NEW PERMIT F-] 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOS K ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE �8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 3 Ci3 �. L / FARM TANK-YES❑ NO Q � I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY w A. OWNERS TANK IO 0 B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: �� II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. i MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C- [Ell' ' UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL © P1 RODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ' ❑ 5 HAZARDOUS ❑ BO EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) I D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF / J HAZARDOUS SUBSTANCE STORED&C.A.S.k C.A,S.t1: 1J III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,0,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM2 SINGLEWALLED ❑ 4 SECONDARY CONTAINMENT 0 ❑ 99 OTHER STEELIIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS a 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 6 10096 METHANOL COMPATOLE FRP MATERIAL ❑ 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 1 RUBBER LINED F—] 2 ALKYD LINING F—] 3 EPDXY LINING 4 PHENOLIC LINING LININC. INTERIOR ❑5 GLASS LINING UNLINED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? YES ❑ NO ❑99 OTH>R D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTIONE�j 91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A rA SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A 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 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 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 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8-5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING ,P'jS 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I 1. ESTIMATED DATE LAST US (MO R) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH 1 / SUBSTANCE REMAIMNG IN INERT MATERIAL? ❑YES ❑ NO GALLONS THIS FORM HAS FEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME{PAINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION AGENCY# FACILITY-ID-g TANK ID# _ �-- CURREN�LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE �r 31� _• PERMIT NUMBER - PERMIT APPROVAL DATE / PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: � FORM B(6-29-88) THIS FORM MUST BE ACCOMPANI A'FACILITYlS1TERPPLICATION, FORM `A',UNLESS A M RENT FORMA' HA5 BEEN FILED J ., LOCAL AGENCY COP—Y——__—r-- ,- .;,, Y _ ►