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vr\ STATE OF CALIFORNE WATER RESOURCES CONTR BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION �wmr&c, c n oFvmnn I C rvnm Yn I n Inc r V LLV W IIf1U INr VHMA I I VN r V H CAUM I ANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ANK ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: f:' lj�FARN TANK -YES NO TANK DESCRIPTION rnuP1 FTF Al I ITF.. _ m uucunwu — en enermv 195-20 6 A OWNERSTANKID# B. MANUFACTURED BY: C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL C YEAR INSTALLED D. TANK CAPACITY IN GALLONS Q II. TANK OONTENTS IF (A.1). IS MARKED. COMPLETE ITEM C. IF /A.11. IS NOT MARKED- COMPI FTF ITFM n / A 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. BLE WALLED C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL F-13 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ W 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 8 C.A.S. R C.A.S. W III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, A D IV A. TYPE OF BLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER 2 PRESSURE 1 5TEELPRON ❑ 2 STAINLESS STEEL ❑3FIBERGLASS ❑4STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK F-1 F-15 CONCRETE ❑ 6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑ B 100%METHANOLCOMPATIBLEFRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING 3 EPDXYLINING ❑ /PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINEDWg NKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO �THER D. CORROSION ❑ I POLYETHLENEWRAP ❑ 2 TAR OR ASPHALT ❑ 3PMWRAP ❑ 4 FI8ERGLASSREINFORCEDPLAsrIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 1915 UNKNOWN ❑ 99 OTHER r lruY9a nYrVnm I WIY UIHULE A FABUVE GROUND, UP IF UNUERGROUND, BOTH IF APPLICABLE 4 ELECTRONIC MONITOR P A. SYSTEM TYPE A l SUCTION A U 2 PRESSURE A U 3 GRAVITY AU 91 NONE 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 U 95 UNKNOWN :[64j95 A U 99 OTHER C. MATERIAL A A A U 1 STEEL/IRON A U 5 ALUMINUM A6 U 9 GALVANIZED STEEL A U 2 STAINLESSSTEEL CONCRETE 95 UNKNOWN A U A U A U 3 POLYVINYL CHLORIDE (PVC) A U 7 STEEL CLAD W/FRP A U 99 OTHER 4 FIBERGLASSPIPE A U 91 NONE 8100% METHANOL COMPATIBLE FRP V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY OR S FOR %FCONOARV A PRIMARY LEAK DETECTION SYSTEM MUST RF CIRCI Fn /I S I VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 3 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS jR I dP S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I APPROVED BY NAME PHONE R WITH AREA CODE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH FACILITY ID #nn SUBSTANCE REMAINING IN 1 INERT MATERIAL? ❑ YES ❑ NO GALLONS O b L O v THIS FC YM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND C( APPLICANT'S NAME (PRINTED & SIGNATURE) DATE LOCAL AGENCY USE ONLY RRECT. COUNTY # JURISDICTION # AGENCY # FACILITY ID #nn TANK ID # O b L O v Vhh O Io E CURRENT LOCAL AGENCY FACILITY ID R / I APPROVED BY NAME PHONE R WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE (� —7,2, CHECKk PERMIT AMOUNT SURCHARGE ANT. FEE CODE RECEIPTR B�Y�%LG ORM 3 (6-29-33I THIS FORM MUST BE ACCOMP� I BY A FACILITYISITE APPLICATION, FORM 'A', UNLE ;URRENT FORMA' HAS BEEN FILED �' DATA PROCESSING COPY \J