SITE INFORMATION AND CORRESPONDENCE

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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM - : TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. . I 1 NEW PERMIT z MARK ONLY ❑ ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT6 TEMPORARY TANK CLOSURE RB TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: CA) FARM TANK-YES 0 NO W I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY N A. OWNERS TANK ID h Cd B. MANUFACTURED BY: 01C. YEAR INSTALLEDL4111,,hLD. TANK CAPACITY IN GALLONS: 0 II. TANK PONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. AT�j 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. I UNLEADED LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT 4 OIL r 1 PRODUCT 4 GASAHOL 5 JET FUEL 6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY [:]95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL [j99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.q: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.S.C,A D A.TYPE OF ❑ I DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM 2 SINGLEYypLLEp 4\ ❑4•S�CONDARYCONTAINMENT ❑99 OTHER 5TEELRIRON ETE B. ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM 8 100%MEFHANOLCOMPATIBLEFRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑2 ALKYD LINING; ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING i ❑6 UNUNED ❑95 UNKNOWNS ❑ IS LINING MATE(iI�L COMPATIBLE WITH I0d%METHANOL? ❑YES [:]NO OTHER 1 1).CORROSION ❑ 1 POLYETHLENE TRAP ' ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑S CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE tiT SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION U 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 I 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 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 6 100%METHANOL COMPATIBLE FRP A 69 ALVANIZED 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 b0aS I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 6 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING.P S 7 PRESSURE TESTING 1 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE MAINING IN Iy T GALLONS ATERIAL? E]YES Ej NO I`J 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 M JURISDICTION 9 AGENCY M FACILITY ID M TANK IO# EEI I --I.. . I I D I I [LI) 1.0 7 Qo 10 111 CURRENT LOCAL AGENCY FACILITY ID E APYEBY HAM PHONE k WITH AREA CODE PERMIT NUMB //!Y[ PERMIT APPRO L D PERJ<IIT EXPIR TION DATE L CHECK! PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: FoRM a(6-29-ss) THIS FORM MUST BE ACCOMPANIED FACILITY/SITE APPLICATION, FORM 'A',UNLESS A-CUl'RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY