SITE INFORMATION AND CORRESPONDENCE

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j .. .�.. r .c. ....a.,-.;:.s-- r :s: v ....r..-z :� *.� �.z --.:,►,. `#.�,:, '.,�:$..u:c�, lr :.y.ci S.7-. i. I V. STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD s FORM `B': UNDERGROUND STORAGE TANK PROGRAMq'� - TANK PERMIT APPLICATION INFORMATION = F TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT S CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TA ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVE l FACILITY/SITE NAME WHERE TANK IS INSTALLED: ILO ,L �' FARM TANK-YES❑ NO, 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY i A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.11),13 NOT MARKED,COMPLETE ITEM O. A. W 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 ❑ BO 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.It C.A.S.p: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D j A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 S#NGLE WALLED WITH EXTERIOR LINER ® 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL ❑5 CONCRETE E]6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 10M METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ® 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED El2 ALKYD LINING ❑ 3 EPDXY LINING ' ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINED ®95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH TOD%METHANOL? ❑YES ❑ NI ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYLWRAP ❑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 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 LIMED TRENCH A U 91 NONE A(U) 95 UNKNOWN A U 99 OTHER A U 1 STEELPRON 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 UU6 CONCRETE A V 7 STEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A S95 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. 04 P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P!S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S I PRESSURETESTING P S 91 NONE P!S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED{MO/YH) 2. ESTIMATED QUANTITY OF 1 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN j INERT MATERIAL? ❑YES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TQ THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) DATE I LOCAL AGENCY USE ONLY ECOUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# �l Lod� FT I q- I & I _/1 Lo I olH�l CURRENT LOCAL AGENCY FACILITY ID# AP,PRRQVED 51�NAME Fj PHONE#WITH AREA CODE L NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE # PERMIT AMOUNT �ilp-- AMT. FEE CODE 13 _IPT# BY: FORM a(6-29-88) THIS FORM MUST BE ACCOMPANIED sT A FACILITY/SITE APPLICATION, FORM `A',UNLESS A CURRENT FORMA' HAS BEEN FILED - "' FJLE COPY