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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INfORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWIN FORMATION FOR EACH TANK. Q ' MARK ONLY ❑ I NEW PERMIT ❑ D RENEWAL PERMIT S CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM - 2 INTERIM PERMIT 6 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED Cj 7 FACILITY/BITE NAME WHERE TANK 18 INSTALLED: �S� FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY A OWNERS TANK ID N _ B. MANUFACTURED BY: Tq p Y•-�- � C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: T( II. TANK CONTENTS IF(A.1)r 18 MARKED,COMPLETE ITEM C.IF(At),IS OT MARKED,COMPLETE ITEM D. A. ❑ I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑G DIESEL ❑O EMICAL PRODUCT ❑ 1 OIL 1 PRODUCT ❑A GASAHOL ❑ 5 JET ❑ 6 AVIATION GAS 5 HAZARDOUS ❑ 60 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL OTHER(DESCRIBE IN ITEM D•BELOW) D. IF NOT MO VEHICLE FUEL,ENTER NAME OF /V,,5; /1/�Pu �O Lw1h,d SU/ N HAZARDOUSS SUBSTANCE STORED 6 C.A.S.N 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A.B.C,aD A.TYPE OF ❑ I WALLED ❑]SINGLE WALLED WITH EXTERIOR LINER ❑95 UNDDNx SYSTEM 2 SINGLE WALLED ❑ 1 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEUIRON ❑2 STAINLESS STEEL [:]7 FIBERGLASS F-1/STEEL CULARS D W/FIBERGREINFORCED PLASTIC B,MATERIAL ❑ 5 rE ❑ 6 POLYVINYL CNLORIDE ❑ 7 ALUMINUM ❑e I OL COMPATIBLE TRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UIBWOWN OTHFA C.INTERIOR ❑ 1 RUBURUNED ❑ 2 INING ❑0 EPDXY LINING ❑A PRENOLICUNIN3 LINING ❑5 MASS LINING 6 UNLINED ❑ 95 UW14 M ❑IS LINING MATERIAL COMPATIBLE WITH ICA WHAMOL7 ❑YES ❑No ❑ 99 OTHER D.CORROSION ❑ 1 POLYETNumwRAP ❑2 TAR ASPHALT ❑ 2 WNL WRAP E]T FIBCAGLAM REINFORCED PLASTICPROTECTION [:] 5 CATHODIC PROTECTION ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IFUNOERGROUND,BOTH IFAPPLICA13LE A.SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 9 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A 0 SINGLE WALLED A U 2 DOUBLE WALLED A U 9 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U I STEEUIRON A U 2 STAINLESSSTEEL A U 9 POLYVINYL CHLORIDE(PVC) A U / FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U B HD METHANOLCOMPATIBLE 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. LP P 1 1 VISUAL CHECK P 5 2 INVENTORY RECONCILATION P 1 9 VADOSE WELLS P t 1 ELECTRONIC MONITOR P t s GROUNDWATER MONITORING WELLS 1. 6 PRECISION TESTING P 6 ?PRESSURE TESTING P t 91 NONE P B 9S UNKNOWN P 6 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST U$EO(MO/YR) 2.ESTIMATED QUANTITY OF 0.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS I INERT MATERIAL? r-1YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPUCANT'S NAME(PRINTED A SIGNAI URE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION N AGENCY/ FACILITY ID N TANK 10 N Q1J L I I I LJ_I I lolo _ -IO 1 u 1 u CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAYS PHONE I WITH AREA CODE PERMRNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECKS PERMIT AMOUNT RCHARGE AMT. FEECOGE RECEIPT By: {O{IY N,A.9Y.M1 THISFORM MMT RF ADCOYBAYICG OYA[�PR rtV,mx�„n In•nno CIYOAI iAr nu,.....,,,.,...,. .,,...... .............�