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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 FOLLOWING INFORMATION FOR EACH TANK. -_- z 10 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT Elr5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDEDPERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑9 TANK REMOVED / Z, ' FACILITY/SITE NAME WHERE TANK IS INSTALLED: Z X4 tk4lA- FARM TANK-YES❑ NO N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY N A. OWNERS TANK IDR C2 I I B. MANUFACTURED BY: C. YEAR INSTALLED l4tll� � I D. TANK CAPACITY IN GALLONS: /,00 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED �2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL 21, PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN REM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.# C.A.S.A: / III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,a D A. TYPE OF ❑ I UBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM 2%GLEWALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER lell STEEL/IRON ❑2 STAINLESS STEEL ❑3FIBERGLASS ❑ 4STEEL CUD W/RBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ MATERIAL 6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ W OTHER C. INTERIOR ❑ I RIBBER LINED ❑2 A KYD LINING F-13 EPDXY UNING ❑ 4 PHENOLIC LINING LINING ❑5 GLASS LINING NUNED ❑ 95 S UNKNOWN ,/ ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES [—] NO �9B-OTHERIL/'LJ � D. CORROSION ❑ i POLYETHLENEWRAP ❑2 TARORASPHALT ❑-1�3 VINYL WRAP F-14 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION E-] 1--k g 91 NONE LUNKNOWN ❑ 99 OTHER IV. PIPING INFORMA ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION U SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 9/ NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A &5 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. FI�t P 8 1VISUAL CHECK P S 2 INVENTORYRECONCILIATION 3VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS !U� P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 1 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATE DATE LAST USED(MO/YR) 2. ESTI TED QUANTITY OF 3.WAS NK FILLED WITH A SU 5(JCE REMAINING IN INE TERIAL? ❑YES ❑ NO /4 GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY k JURISDICTION P AGENCY k FACILITY ID N TANK ID 8 Do C?- = I dodr CURRENT LOCAL AGENCY FACILITY ID• APPROVED BYN E PHONE k WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE IPERMIT EXPIRATION DATE / CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT* BY: FORM D(6-29-88) THIS FORM MUST BE ACCOMF..,..0 oY A FACILITY/SITE APPLICATION, FORM `A',UNUM*''--ARENT FORMA' HAS BEEN FILED DATA PROCESSING COPY I