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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM B': UNDERGROUND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION TANK 6"' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EAC"TANK. MARK ONLY 711 NEW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVED D FACILITY/SITE NAME WHERE TANK IS INSTALLED: P o r t 0 f S t 0 C k 0 OF O b d D i s t . FAIIM TANK-YES❑ molM I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK IDN B. MANUFACTURED BY: Unknown C YEAR INSTALLED Unknown D. TANK CAPACITY IN GALLONSZOO O 11. TANK CONTENTS IF IA.%IS MARKED,COMPLETE ITEM C.IF(AL1),IS NOT MARKED,COMPLETE ITEM D. A. ® I MOTOR VEHICLE FUEL 2 PETROLEUM B. C. ® 1 UNLEADED 2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑A OIL ® 1 PRODUCT ❑/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 HAZARDOUS SUBSTANCE STORED 8 C A.S.N C.A.S.N: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOE A.B,C.A D A.TYPE OF ❑ I O0JBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UWR ❑%UNKNOWN SYSTEM ®2 SINGLE WALLED ❑A SECONDARY CONTAINMENT ❑99 OTHER ® I STEELIRON ❑2 STAINLESS STEEL ❑3 RBIRGLASS 1 STEEL CUD WIRBERGLASS REINFORCED PLASTIC B.TAM( ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑B 1OD%METHANOL COMPATIBLE RIP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑%lMl(NO%N ❑99 OTHER C.INTERIOR F-1I RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOUC UMNG LINING ❑5 GLASS LINING ®6 IAEJNED ❑%UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH IW%METMNOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑1 POLYETNENE WRAP ®2 TAR OR ASPHALT ❑3 WNR WRAP ❑1 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 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U t SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER U 1STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYLCHLORIDE(PVC) A U A FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 1W METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U M UNKNOWN A U "OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY.A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. A I VISUAL CHECK 0S 21NVENTORY RECONCILIATION ► S 3VADOSE WELLS P S AELECTRDNIC MONITOR P t SGROUND WATER MONITORING WELLS P 6 PRECISION TESTING P S 7 PRESSURE TESTING P B 91 NONE P S 95 UNKNOWN P $ "OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OFaAuoNE 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? [:]YES ❑NO ) THIS FORM HAS BEEN COMPLETED UNDER PENALTY OfPERJURY.AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE Randy Thomas LOCAL AGENCY USE ONLY COUNTY S JURISDICTION• AGENCY N FACILITY ID 0 TANK ID 0 CURRENT LOCAL ABENCY FACT TY IDI APPROVED BY NAME PIgM[N WITH MG CODE o,e-}� ao PERMIT NUMBER PERMIT APPROVAL DATE BIMINI EXPIRATION DATE e-L6-9 0 CHECK E PERMIT AMOUNT SURCHARBE AMT. mm CODE BEC[IR P EY: p FORM 818-29-881 THIS FORM MUST NA000N"*AWBYAFACARTIMR AII{IGiKSA FORM'A',URL'--•.CImmfT 10IBI•A' LMB BEEN FILED L D),.^ PROCESSING COPY 2 LOCAL AGENCY cbw 3 FMR COPY