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STATE OF CALIFORNIA WATER RESOURCES CONTROL )ARD FORM BI: UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION % COMPLETE A SEPARATE FORM TH THE FOLLOWING IN RMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ENEWALPERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: Q 40,615h 1j, FARM TANK-YES❑ NO •C I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY '? A. OWNERS TANK ID 4 I B. MANUFACTURED BY: W C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. CD A ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑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 6 CAS.R CAS.M: III. TANK CONSTRUCTION MARKONEITEMONLYINBOXA,B,C,aD A TYPE OF ❑-1 DOUBLEWAUID ❑3 SINGLE WAULD WITH WEROR LINER ❑95 UNKNOWN - SYSTEM ❑2 SINGLE WALLS) ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEB/IRON ❑2 STAINLESSSTEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WMEIERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑81W%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ 1 ROBBER LINED ❑2 ALKYD LINING ❑3 EPOKYUNING ❑4 PHENOLICUNING LINING ❑5 GLASS LINING ❑6 UNUNED ❑95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 180%ME7HANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAA OR ASPHALT ❑3 VINYL WRAP ❑4 RBERGLASSREINFOPCEDPLA5TIC PROTECTION ❑ 5 CATHKODICPROTECRON ❑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 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 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U 8 100%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. 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 8 6 PRECISIONTESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 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 INLUILLON8 INERT MATERIAL? ❑YES 0 N THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED B SIGNATURE) DATE V� LOCAL AGENCY USE ONLY COUNTY B JURISDICTION B AGENCY 8 FACILITY ID B TANK ID x a \ L I / CURRENT LOCAL AGENCY FACILITY ID F APPROVED BY MANE PHONE•WITH AREA CODE N vl PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK• PERMIT AMOUNT _ SURCHARGEAMT. FEE CODE RECEIPT BY: FORM B(6-29-e8) THIS FORM MUST BE ACCOMPANIED BY A FACILRY/SITEAPPLICATIOK FORM 'A',UNLESS A CURRENT FORMA HAS SEEN FILED nATa PROCESSING COPY