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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 ❑ 1 NEW PERMIT F13 RENEWALPERMR 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVE / FACILITY/SITE NAME WHERE TANK IS INSTALLED L7W !%- 7q,*- ' FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY l A. OWNERS TANK ID `/ v B. MANUFACTURED BY. U/L/ C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS:Uf _?OV W H. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. rsa A. ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. �Q C. 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL W 9 ❑3 CHEMICAL PRODUCT ❑1 ' OIL ❑ 1�PRODUCT ❑<GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ©-- 1 A$TE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM 0 BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# /'3- /v / C.A.S.#r 13 .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTE If 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEL/IRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TAN /7/ ❑ 5 CONCRETE ❑ 6 POLriINYL CHLORIDE ❑ 7 AL INUM ❑ B 100%METHANOL COMPATIBLE FRP MATE L ❑9 BRONZE ❑10 GALVANIZED STEEL LpM UNKNOWN ❑ 99 OTHER — ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY UNING ❑4 PH LICUNING C. INTERIOR ❑ 5 GLASS LINING ❑6 UNLINED 5 UNKNOWN /� ❑ IS UNING MATERIAL COMPATIBLE MTH t00R MEMAN ❑YES NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VW WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE Ek4uNKNOWN ❑ 99 OTHER IV. PIPING INFO _ NATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYP A U 1 SUCTION A U 2 PRESSURE A 3 GRAVITY A U 99 OTHER R.CONSTRUCTI A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A'6 3 UNEO TRENCH A(PZ) UNKNOWN A U 99 OTHER / A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(P ) A U 4 FIBERGLASS PIPE C. MATERIAL /Y A U 5 ALUMINUM A JL 4 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A/N H5 UNKNOWN A U 99 OTHER V. LE ETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 1 VISUAL CHECK P 9 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS tn.lp P S 6 PRECISION TESTING P S ] PRESSURE TESTING 9-41 1 NONE P S 95 UNKNOWN P S 99 OTHER �VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE TIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITH N SUBSTANCE REMAINING IN GALLONSINERT MATERIAL? ❑YES E] NO THIS FORM HAS BI COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY VENT JURISDICTION# AGENCY# FACILITY ID# L7 TANK ID# oUao aba:GENCY FACII ID# VED BY NAMEPHONE 0 WITH AREA CODE R r/C9' 8gVe PERMIT APPROVAL DATE PERMIT TION DA CHECK# PERMIT AMOUNT _ SURC HIUMEAMT. FEECODE RECEIPT BY: oRM B 13a 7 THIS FORM MUST BE ACCOMPANIPC$Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS ATARRENT FORMA HAS BEEN FILED