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STATE OF CALIFOR& WATER RESOURCES CON10L BOARD , FORM IBI: UNDENOROUND 9TORAGa TANK PROGRAM TANK > TANK PERMIT APPLICATION INFORMATION CdMPLEti A ikPANAtE PONM WITH tHE FOLLOWING INFORMATION Pop EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑S RENEWAL PERMIT ❑6 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 21NTERIM PERMIt ❑/AMENDEDPERMR ❑6 TEMPORARY TANK CLOSURE ❑0 TANK REMOVED O7 FACILFFY/01TE NAME WHERE TANK It INSTALLED: 6'5-S / f FARM TANK-YES❑ NO ) r 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID 01 B. MANUFACTURED BY: c. INSTALLED D. TANK CAPACITY IN GALLONS: SOD 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 C ❑ I UNLEADED ❑2 LEADED ❑3 DIESEL ❑3.CHEMICAL PRODUCT ❑ A OIL �PRODUCi ❑A GASAHOL ❑ 5 JET FUEL ❑0 AVIATION OAS 5 HAZARDOUS ❑00 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED A C A.S.0 ��/—� S /Z—� C.A.S.A: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B,C,A D A TYPE OF ❑ I DOABLE WALLED ❑0 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGE*AM ❑I SECONDARY CONTAINMENT ❑99 OTIEA " B.TANK ❑ 1 SEER/PON ❑ 2 SIAINLESSSIEEL ❑1 FIBERGLASS ❑1 STEEL CAD WIRBEAOUSS REINFORCED PLASTIC — MATERIAL ❑S CUHOETE ❑A POLYWWLCROPM ❑ 1 ALUMINUM ❑e l(K6METHANOLCOMPARBLEFRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. MtERIOR ❑ 1 RUBBER LWA ❑2 tRANo ❑3 EPDXY UTRNG ❑1 RENOLICURINO LIN" ❑5 M"LoWn UAINED ❑95 UNKNOWN ❑BL"W UATMAL MWATW wr H Im1L MERUNa7 ❑YES ❑No ❑99 OTHER D. CORROSION ❑ 1 POLM"AFEWRAA ❑2 ASPHALT ❑3 VINYLWRAP ❑ ,TIREROLAs9REINFORCEOPLASTIC PROTECTION ❑5 CATHOM PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFOhMATION 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 95 UNK A U 99 OTHER B.CONSTRLMiWNSINGLE W A U 2 DOABLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER I A U 2 9TAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U I FIBERGLASSPIPE A U 91 NONE C. MATERIAL �A U 6ALUMINUM A U !CONCRETE A U 7STEEL CLAD W/FRP A U B IDB%METHANOL COMPATISLEFRP A U 6 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. P 1 IVI9UAL CHECK P 6 2 INVENTORY RECONCILIATION 0 6 3VADORE WELLS P ! / ELECTRONICMONItOR P 6 SGROUNDWATER MONITORING WFLL9 P 6 e PRECISION TESTING P 6 1 PRESSURE TESTING '91-f(r1N�` ► ! 95 UNKNOWN P 6 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE UST USED(MO/YRI 2.ESTIMATED OIANTRY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING BI GALLONS INERT MATERIAL? ❑vES ❑ THIS FORM NAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. =ME)PRINTED A SIONATUREI DATE LOCAL AGENCY US ONLY COLNITY E JURISDICTION E P'�AGENCY A FACILITY ID A TANK ID 0 L/' CUIIRlIR LOCAL AGENCY PACBITY KI 6 APPROVED 6r NAY! PHONE/WITH AREA COD[ .P/s i a� PERYR NUY6ER PERMIT APPROVAL DAT! PERMIT EXPIRATION DATE CHECK PERMIT AMOUNT 61RCHAROP AMT. FEE CODE RECEIPT er:� row R(9.29-eel THIS FORM MUST BE ACCOMP Y A FACILITY/61TE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS SEEN FILED