SITE INFORMATION AND CORRESPONDENCE

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zPyF„ ''�f')''1 �'?.1..�y�'V:K. ,� , r�;•Yi" ' k. _ 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. MARK ONLY ❑ ❑ LTJ ❑ I 1 NEWPERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMO caa FACILITY/SITE NAME WHERE TANK IS INSTALLED: 9U I Iff , ( I t -tp t FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SOSPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: 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. A. 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. ❑ 1 UNLEADED ® 2 LEADED 3 DIESEL 6 3 CHEMICAL PRODUCT ❑4 OILw1 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.If I C.A.S.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D I A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ®95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER i 1 STEELlIRON ❑ 2 STAINLESSSTEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD WlFIBERGLASSREINFORCED PLASTIC i B.TANK 5 CONCRETE 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANlZEDSTEEL Y] 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑5 GLASS LINING 6 UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPAT13LEWITH 100%METHANOL? YES ❑ NO 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION [—]5 CATHODIC PROTECTION ❑91 NONE ® 95 UNKNOWN 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE AC�b 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 2 95 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 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A(D 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. i P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 6 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS f ✓r �I P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE 1� S 95 UNKNOWN P S 99 OTHER 5 VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF i 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES NO GALLONS 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 i LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 3LoloMqI (Ji - I qac CURRENT LOCAL AGENCY FACILITY ID A APPROVEDWBYNAME I J� PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK 8 PERMIT AMOUNT SURCHARGE ANT. FEE CODE EIPT iE BY; I I FORM B(6-29-BS) THIS FORM MUST BE ACCOMPANIELs1'A FACILITY/SITE APPLICATION, FORM IN,UNLESS A CURENT FORM-N HAS BEEN FILED - '� Ilk FILE COPY r_