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STATE OF CALIFORN WATER RESOURCES CONTRA _ IOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THF FnI 1 FOR .... C_. A ---____.....�.... .......,�„ .FCri 1ANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 0 7 P MANENTLY CLOSE ONE ITEM ❑ 2 INTERIMPERMIT ❑ 4 AMENDEDDPERMITT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED /D 9 FACILITY/SITE NAME WHERE TANK IS INSTALLED: 335q A. � FARM TANK YES O ❑ vv..n.r IIVIll {:VMPLETE LLLITEYR.IF IIYKYnWu-en enen.v.r A. OWNERS TANK ID# �B. MANUFACTURED BY: K C. YEAR INSTALLED Lw D TANK CAPACITY IN GALLONS: :5 000 ... -r LA.7J, 13 MAHRED, COMPLETE ITEM C. IF (A 1) IS NOT MARKED COMPLETE ITEM A E�ri MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B D. C. ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 1 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. # C.A.S. #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B. C.8 D A TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER UalrUNKNOWN SYSTEM ❑ 2 SINGLE WAILED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER UNKNOWN ❑ 1 STEELARON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8100%METHANOL COMPATIBLE FRP A 5 UNKNOWN ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING F-13 EPDXY LINING ❑ 4 PHENOLIC UNING LINING ❑ 5 GLASS LINING ❑ fi UNLINED A ,i UNKNOWN 5 ALUMINUM ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO Eg-grOTHDI D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TARONASPHALT ❑ 3 VI WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 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 NONE5 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 5 UNKNOWN A U 99 OTHER BY: A U 1 STEELPRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100% METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A 0 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 B I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8-&VAADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS '� lr P 5 6 PRECISION TESTING P S t PRESSURE TESTING L/P 8S 4 ONE 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 QUANTITY OF 3. WAS TANK FILLED WITH TANK ID # SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES [:]NO I APPR� ED BY NAME � GALLONS PERMIT NUMBER THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME (PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY C�ODUmINTYY # 13 JURISDICTION # = AGENCY # FACILITY ID # /�-y/ O / / o TANK ID # CURRENT LOCAL AGENCY FACIL/TZ' ID • L3 APPR� ED BY NAME � PHONE k WRTI AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PI MIT EXPIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT If BY: FORM B (5-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A', UNLESS A CURRENT FORMA' HAS BEEN FRED DATA PROCESSING COPY G 10