SITE INFORMATION AND CORRESPONDENCE

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STATE-OPCALIFORN.' WATER RESOURCES.CONTF BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM !'` TAN K TANK PERMIT APPLICATION INFORMATION r COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. LSV MARK ONLY , ..❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5k CHANGE OF INFORMATION ❑ 7 PE NENTLY C I ' . ONE ITEM �, ❑2 INTERIM PERMIT - ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE `i TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: M FARM TANK-YES❑ NO Ca I. TANK DESCRIPTION coMPLETE ALL ITEMS-IF UNKNOWN—So SPECIFY pp A. OWNERS TANK ID 111B. MANUFACTURED BY: ' G. YEAR INSTALLED } } D. TANK CAPACITY IN GALLONS: It. TANK CONTENTS 'IF(A-1),IS MARKED,COMPLETE ITEM C.IF(A.11).IS NOT MARKED,COMPLETE ITEM D. A. [—] I MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED 0,'2 LEADED ❑ 3 DIESEL 1 ❑3 CHEMICAL PRODUCT ❑ 4 OIL , r ❑ 1 PRODUCT ❑ 4 GASAHOL D.:5 JET FUEL ❑$AVIATION GAS ❑5 HAZARDOUS :❑ 80 EMPTY ®95 UNKNOWN ❑2-WASTE - ❑ 7 METHANOL ❑;99 OTHER(DESCRIBE IN ITEM D,BELOW) I D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.MC.A.S. 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.&D A.TYPE OF F-1-1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ®95 UNKNOWN SYSTEM ❑2 SINGLEWALLED E]4 SECONDARY CONTAINMENT ❑99 OTHER F 1 STEELIIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK NCRETE B POLYVINYL CI ILORIDE 7 ALUMINUM ❑ ❑ ❑8 100%METHANOL COMPATIBLE FRP ' MATERIAL 9 BRONZE ❑ 10 GALVANIZED STEEL611wrlalw i ❑'99 OTHER ❑ 1 RUBBERUNED ❑2 AU(YOUNING ❑3 EPDXY LINING ]❑4 PHENOUCUNING C.INTERIOR ' r LINING " ❑5 GLA55UNING ❑8 UNLINED ®95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 19096 METHANOL? ❑YES ❑NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP „ ❑2 TAR OR ASPHALT ❑3 VINYL WRAP i❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION "❑5.CATHODICPROTECTION ❑91 NONE ®95 UNKNOWN 1 0 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 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 A95 UNKNOWN A U 99 OTHER A' U 1 STEEL/IRON. A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL" A U 5 ALUMINUM A U"8 CONCRETE A U 7 STEEL CLAD WIFRP A U 8!100%METHANOL COMPATIBLE FRP A U $GALVANIZED STEEL A 95 UNKNOWN " A U 99 OTHER; LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P 8, 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P B;k 5 GROUND WATER MONITORING WELLS P S 8 PRECIS ION TESTING P S 7 PRESSURE TESTING P B 91 NONE P BI 95 UNKNOWN P 5 99 OTHER V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I.-ESTIMATEDAATE LAST USED(MOYYR) 2.ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH" ND'T KAIAM SUBSTANCE REMAINING IN Ij GALLONS INERT MATERIAL? YES ❑NO A Oe�y •F 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 !M. COUNTY M JURISDICTION M AGENCY M [FACILITY IDM 1 TANK ID M I EE 1- 1 1 -1 ' 11 (g, 9 t D lo I o CURRENT LOCAL AGENCY FACILITY 10 P APPROVED BY NINE PHONE N WITH AREA CODE ` p PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 1 is r CHECK/ PERMIT AMOUNT IRCHARGE AMT. FEE CODE � `uPT✓f BY: FORM B(6-29-aa) THIS FORM)MUST BE ACCOMPANIE �FACIU"ISI'Tni APPLICATION, FORM 'A',UNLESS ARENT-FORMA HAS BEEN FILED _ # ` � - �.•.n. -__nATe nRA(`aFCCIAIr_CAov_