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STATE OF CALIFORN WATER RESOURCES CONTR 30ARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY 1 NEW PERMIT ❑ 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 REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: �� rpt% LjIJ, FARM TANK - YES ❑ NO ' 1. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. OWNERS TANK ID # ❑ 1 DOUBLE WALLED B. MANUFACTURED BY: ❑ 95 UNKNOWN C. YEAR INSTALLED R2 SINGLE WALLED D. TANK CAPACITY IN GALLONS: C) I ANK L;VN 1 LN I' IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. A. Zl MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑'LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL el -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. # ^/ /-A C.A.S. #: A / TANK C0NSTRl1CTInN MARK ANF ITFM ONLY IN ROY A- R- C- A D !� A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM R2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER U 2 PRESSURE ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL [�T3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A F-11 RUBBER LINED ❑ 2 ALKYD LINING � 3 EPDXY LINING F-]4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNLINED C. MATERIAL ❑ 95 UNKNOWN U ❑ IS LINING MATERIAL COMPATIBLE WITH 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 INFORMAT N CIRCLE A IFABOVEGROUND, U IF UNDERGROUND, BOTH IF APPLICABLE 3, WAS TANK F LLED WITH FACILITY ID # A. SYSTEM TYPE A U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER APPROVED BY NAM B. CONSTRUCTION A( -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 PERMIT APPROVAL 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 ,. 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A ULJ�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 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 ! 6 PRECISION TESTING S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER �I. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED TE LAST USED (MO/YR) 2. ESTIMATqj QUANTITY OF 3, WAS TANK F LLED WITH FACILITY ID # SUB FyR�MAINING IN INERT RI L? ❑ YES ❑ NO t GALLONS LoLo 3 1 THIS FORM HAS BEEN COMPLETED UNDER PENALTY & PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME (PRINTED & SIGNATURE) DATE 1 (1(`AI AtFKli-v I ICF ()N1 v COUNTY # JURISDICTION # AGENCY # FACILITY ID # TANK ID # LoLo 3 1 L616 3 CURRENT LOCAL AGENCY FACILITY ID # APPROVED BY NAM PHONE # WITH AREA CODE 3 lei Z PERMIT NUMBER PERMIT APPROVAL PERMIT EXPIRATION DATE IA CHECK # PERMIT AMOUNT SURCHARGE A FEE CODE RECEIPT # BY: FORM B (6-29-88) THIS FORM MUST BE ACCOMPAINIM A FACILITY/SITE APPLICATION, FORM `A', UNLESS RENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY :. 19 tV 00 CJI