SITE INFORMATION AND CORRESPONDENCE

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STATE OF CALIFORNIA WATER RESOURCES CONS ROL BOARD { FORM B': UNDERGROUND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION `- TANK : 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 CLO ED T ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE Q 8 TANK REMOVED D 17 FACILITY/SITE NAME WHERE TANK IS INSTALLED: �/� � FARM TANK-YES❑ NO (� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK IQ# 0. MANUFACTURED BY: C■J C. YEAR INSTALLED x D. TANK CAPACITY IN GALLONS: QV 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM i EL. C. 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS - ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM O,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF l t HAZARDOUS SUBSTANCE STORED&C.A.S.# A C.A.S.#: III. TANK CONSTRUCTION (NARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF I18LE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT El 99 OTHER i 1 STEELPRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-]5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 1 ALUMINUM ❑8 10096 METHANOL COMPATIBLE FRP � ❑9 BRONZE ❑ IO GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER F-11 RUBBER LINED ❑ 2 ALKYD LINING', El3 EPDXY LINING ❑4 PHENOLIC LINING C.INTERIOR LINING ❑ 5 GLASS LINING r 6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH I DO%METHANOL? ❑YES ❑ NO OTHER D.CORROSION ❑ 1 POLYETHIENE WRAP ❑ 2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC ; PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ;� UNKNOWN ❑ 99 OTHER g IV. PIPING INFORMATION CIRCLE A IFA E GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A t2/2.PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION AM 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE AU 95 UNKNOWN A U 99 OTHER k 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 5 C. MATERIAL A U 5 ALUMINUM A6 CONCRETE A U 7 STEEL CLAD W/FRP 'A U 6 1OD%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A(995 UNKNOWN A U 99 OTHER 1 V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. JQ P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION 'I 3 VADOSE WELLS P. S 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER - '} VI. INFORMATION ON TANK PERMANENTLYjCLOSED IN PLACE 1.ESTIMATED ATE LAST USED(MO/YR 2. EST[MAT D QUANTITY OF 3.WAST NK FILLED WITH SUB T REMAINING IN IN TERIAL7 A GALLONS ❑YES ❑ NO k THIS FORM HAS BEEN COMPLETED UNDER PENALTY PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. + I APPLICANT'S NAME(PRINTED&SIGNATURE► DATE LOCAL AGENCY USE ONLY '" Fc JURISDICTION# AGENCY# FACILITY 10# TANK ID# I L.d;IT d -L& I-(=t:2 Fo7lo lo T�T AGENCY FACT ID• APPROVED BY NAM PHONE 91NRH AREA CODE $ PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PERMIT AMOUNT UFICHARGE AMT. FEE CODE RECEIPT R BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED FACILITY/SITE APPLICATION, FORM 'A',UNLESS NT FORMA' HAS BEEN FILED e ,. DATA PQ0CESRING rnov