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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'B': UNDERGROUND STORAGE TANK PROGRAM <br /> TANK PERMIT APPLICATION INFORMATION % <br /> TAN K - COMPL <br /> ''! ETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY ❑ I NEW PERMIT G RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM 2 INTERIM PERMIT 1 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE B TANK REMOVED 7 <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: 5 -5 ��Giv FARM TANK-YES O NO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A OWNERS TANK 10# O/ —_/ B. MANUFACTURED BY: <br /> C.YEAR INSTALLED lc( �[ D. TANK CAPACITY IN GALLONS: rj-(� Y <br /> If. TANK CONTENTS IF(A.1).IS MARKED,COMPLETE ITEM C.IF(A.1).IS NOT MARKED,COMPLETE ITEM D. <br /> A f-� 1 MOTOR VEHICLE FUEL [:]2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED G DIESEL <br /> D CHEMICAL PRODUCT 1 OIL - 1 PRODUCT ❑4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS 60 EMPTY E395 UNKNOWN 1-1 2 WASTE 1:1 7 METHANOL Q-96'OTHER(DESCRIBE IN ITEM D.BELOW) <br /> 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF _ tig-c2 CXR <br /> HAZARDOUS SUBSTANCE STORED 6 C.A.S.M Sv c,F� "L, ih C.A.S.N: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,S,C,a 0 <br /> A TYPE OF ❑ I DCIIDLEWALLED ❑0 SINGLE WALLED WITH ERTERIOH UNER 95 UNKNOVM <br /> SYSTEM 2 SINGLE WALLED 1 SECONOARYCONTMNUENT 99 OTHER <br /> I STEEUIRON El 2 STAINLESS STEEL F-10 FIBERGLASS A STEEL CUD WIFIBERGUSS REINFORUO PLASTIC <br /> B.TANK S <br /> MATERIAL [I 6 POLYVIWLCHLOROE r-17 ALUMINUM E]6 I"UEDWOLCOUPATIBUFRP <br /> 9 BRONZE 10 GALVANIZED STEEL 0.95 UNKNOWN F2�99 OTHER -R P <br /> G INTERIOR ❑ I RUBSERUNED 2 ALKYD LINING 0 EPDXY UEONG ❑ I PHENOLCUNNG <br /> LINING ❑ 5 GLASS L06IA E] 95 UNKNOWN <br /> [:] IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES NO 99 OTHER <br /> D.COflR0910N ❑ I FOLYETHLENE WRAP ❑1 T,WOR ASPHALT 0 VINYL WRAP 1 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 1 NONE ❑ %UNKNOWN El 99 OTHDL <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE 1 SUCTION A U 2 PRESSURE A U 7 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B.CON9IAUCTION A U SINGLE WALLED A U 2 DOUBLE WALLED A U 7 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> A U I STEEL/IRON A U 2 STAINLESS STEEL A U 7 POLYVINYL CHLORIDE(PVC) A U / FIBERGLASS PIPE A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 6 IDB%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZEDSTEEL A U 95 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> 1 P S 1VISUAL CHECK P 9 2 INVENTORY RECONCILIATION P S 9VADOSE WELLS P 6 1 ELECTRONIC MON170A P S 5 GROUND WATER MONITORING WELLS <br /> u� P A. a PRECISION TESTING P 6 7 PRESSURE TESTING P 6 91 NONE P S 95 UNKNOWN P 9 99 OTHER <br /> Vi. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> I.ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF F S.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING INGALLONS INERT MATERIAL? F-1YES ❑NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED 6 SIGNAL URE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY P JURISDICTION 6 AGENCY I FACILITY ID 1 TANK IO# <br /> 1 0 1 cl j I 7 `r O G u % <br /> CUBA MT LOCK AGENCY FACILITY ID# APPROVED BY NAME PHONE I WITH AREA CODE <br /> PERMITNUMSER PERMIT APPROVAL DATE PER MIT EXPIRATION DATE <br /> CHECK# PEBMITAMOUNT SURCHARGE AMT. FEE CODE RECEIPT BY: <br /> Co <br /> 1nnM R IA.mmi THIS FORM MAST RP Armunmon RY A cArn"lane Ana,rinnu CYY CI u 1 A, ,,m e.....,.,....u. .......... .... ...... <br />