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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM n TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWINQ,INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑0 RENEWAL PERMIT EEf5CHANGEOF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 1 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: r FARM TANK-YES❑ NO 1 vn I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A OWNERS TANK 10/ - / 7 cJ ' B. MANUFACTURED BY: c -5 C. YEAR INSTALLED y I D. TANK CAPACITY IN GALLONS: S�j II. TANK CONTENTS IF(A.1),18 MARKED,COMPLETE ITEM C.IF(A.1).IS NOT MARKED,COMPLETE ITEM D. A ❑ I JMOTOR VEHICLE FUEL ❑2 PETROLEUM 8. C. ❑ 1 UNLEADED ❑2 LEADED ❑ G DIESEL 0 CHEMICAL PRODUCT ❑ / OIL ) PRODUCT ❑K GASAHOL ❑5 J FUEL E] 6 AVIATION GAS ❑ S HAZARDOUS ❑ 80 EMPTY [:]95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF // HAZARDOUS SUBSTANCE STORED 6 CAS.N /�;� moi/ - DC.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.8,C,A D A TYPE OF ❑ I DOUBLE W91 D ❑ 7 SINGLE WALLED WITH EATER90R LINER ❑ 95 UNKNOWII SYSTEM ❑2 SINGLE WALLED /SECONDAWCONTAINMENT 99 OTHER ' ❑ I STEELIMON ❑2 STAINLESS STEEL ❑)FIBERGLASS ❑ /STEEL CUD WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CNDIETE 6 POLYVINYL atDrd* ❑ 7 ALUMINUIr ❑6 IM%METHANOLCOMPATIBLEFRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL [].95 UNKNOWN 99 OTHER C.INTERIOR ❑ I RUBBERUNED ❑2 ALM LINING ❑9 EPWYUNWG ❑A PHENOLICUNING LINING ❑ 5 GLASS LUNG ❑6 UMJNED ❑95 UNKNOWN ❑ SUNINGMAMRMLCOMPATWMTH100%maHNOL7 ❑YES ❑ NO ❑ 99 OTHER 1).CORROSION ❑ I PoIYERLEIIE WRAP ❑2 TAR OR ASPHALT ❑)WNYLWPAP ❑ I FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 7 GRAVI rY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER 8.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U ]LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U S POLYVINYL CHLORIDE(PVC) A U I FIBERGLASS PIPE A U 91 NONE G MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U 6 160%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 / 1VISUAL CHECK P 5 2 INVENTORY RECONGLIATION P / 3VADOSE WELLS P / 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P %. 5 PRECISION TESTING P 0 7 PRESSURE TESTING P N 91 NONE P / 95 UNKNOWN P / 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATEOOATE LA5i USED(MO/YR) 2.ESTIMATED QUANTITY OFGALLON/ J.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? C:]YES E] 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 SIGNATURE) GATE LOCAL AGENCY USE ONLY COUNTY I JURISDICTION I AGENCY I FACILITY ID I TANK IO N — 1016) 10 CLQ CCSlol ol / l 217 E CURRENT LOCAL AOENCY FACILITY ID I APPROVED RY NAME PHONE I WITH AREA CODE PERMIT NUMOER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE AML CHECK# PERMITAMOUNT SURCHARGE AMT. FEE COD! RECEIPTI er: f DDM R Ib?R.M1 CAO 1A 'A' nm e...m,,.,..... .......... ...............