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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD �f. FORM 'B': UNDERGROUND STORAGE INFORMATIONKOGA TANK TANK PERMIT _ , COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. O MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 1 ERMANENTLYG OS NK ONE ITEM ❑2 INTERIMWERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVED b N / to FARM TANK-YES❑ NO O FACILITY/SITE NAME WHERE TANK IS INSTALLED: FJ 1 00 - I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY Ca A. OWNERS TANK IDR B. MANUFACTURED BY: C. YEAR INSTALLED Ij G D. TANK CAPACITY IN GALLONS. A, U II. TANK EONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM 9. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL V,PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 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 C.A.S.R: HAZARDOUS SUBSTANCE STORED&C.A.S.R III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C.8 D A. TYPE OF ❑ 1 OUBLEWALLED ❑ 3 SINGLE WALLED WITH WSIOR LINER ❑95 UNKNOWN SYSTEM 2 GLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER UNE ❑2 ALKYD UNING [:j3 EPOKYLINING n !AENOUC LINING LINING ❑ C. INTERIOR 5 GLASS LINING ❑6 UNLINED EV95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE MTH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAROPASPHALT ❑3 NYLWRAP ❑4 FIBERGLASS REINFORCE PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION AlU 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 RBERGLASSPIPE A U 91 NONE C. MATERIAL A 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U %OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY.A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 5 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P S 3 VAOOSE WELLS S d ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S I PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLEOMTH SUBSTANCE REMAINING IN GALLONSINERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION R AGENCY R FACILITY ID K TANK ID R 3910101 TS DDo CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY IN PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPN V D PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT R BY: FORM B IB-29-88) THIS FORM MUST BE ACCOMPANIED ILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY