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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM mom' TANK TANK PERMIT APPLICATION INFORMATION o COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - IO MARK ONLY ❑ 1 PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLwP-o ONE ITEM INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: p r- , FARM TANK-YES❑ CN I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY ~ N A. OWNERS TANK ID B. MANUFACTURED BY: (� C. YEAR INSTALLED z CT-5- D. TANK CAPACITY IN GALLONS'. J�O II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. Q ❑ 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 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 HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGE WALLED WITH EGERIOR LINER E] 95 UNKNOWN SYSTEM E]2 SINGLE WALLED F-14 SEGO ARV CONTAINMENT ❑ 99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESSTEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC S.TANK ❑5 CONCRETE ❑6 POLYVINYL Lon ❑7 ALUMINUM ❑B 18090 METHANOL COMPATIBLEfRP MATERIAL ❑9 BRONZE ❑ 10 GALVANRED EL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY UNING ❑4 PHENOUC LINING LINING ❑5 GLASS UNING ❑6 UNLINED ❑95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑ 2TAR OR ASPHALT 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION [�] 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IFDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U i 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 k 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGIASSPIPE A U 91 NONE C. MATERIAL A U S ALUMINUM A U B CONCRETE A U T STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A 11 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR.S FOR SEGO ARV,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P S 5 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO OAlLON8 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT L AL AGENCY FACI4TY IDN APP B NA HONE#WITH AREA CODE Ivo G PERMIT NUMBER / PERMIT110VAL DATE 711 PERMIT FX IRATI N D% 55 � 3 CNECK# PERMIT AMOUNT /SURCHARG�AMT. ss� FEE CODE I I REYIEIPT# BY: 1 15 g-)ORMS(629m) THIS FORM MUST BE ACCOMPAAI BYAl6 FACILITY/SITE APPLICATION, FORM 'A',LANCES RRENT FORMA' HASBEENFILED DATA PROCESSING COPY