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STATE OF CALIFORN WATER RESOURCES CONTI. _ BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION o, COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY © I NEW PERMIT ❑3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: PUISL t S L, Op LON pV W, ,FAR TANK-YES❑ NO ® Z 1. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY IC) A. OWNERS TANK ID# 234_ B. MANUFACTURED BY: qrkl�KL. C. YEAR INSTALLED D. TANK CAPACITYINGALLONS: 12 DUO. W II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. N A ® 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. ® 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑S 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.#: x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.A D A.TYPE OF © 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXIEROR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLEWAUID ❑4 SECONDARY CONTAINMENT ❑99 OTHER © 1 STEBUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 IW%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ I RUBBERLINED ❑2 DLINING ❑3 EPDXY LINING ❑ 4 PHENOLICUNING LINING ❑5 GLASS LINING 8 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2TAR OR ASPHALT :❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION © 5 CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IFAPPLICABLE A SYSTEM TYPE A U 1 SUCTION AU 2 PRESSURE A U 3 GRAVITY A U 99 OTHER IL CONSTRUCTION A U 1 SINGLE WALLED A A 2 DOUBLE WALLED A U 3 LINED TRENCH. A U 95 UNKNOWN A U W OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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 OB i VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS O S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE- 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 OUANTITY OF3.WAS TANK FILLED WITH GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES [-] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 6 SIGNATURE) DATE 2(CNAeI)C_I�IYNA v CLr,- Lo fF ?b b8 j LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# f o CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAM PHONE N WITH AREA CODE __13 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT 1EXPIRAMON DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTN BY: FORMS(3-7-88) THIS FORM MUST BE ACCOMPANIEt f A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A NT FORMA' HAS BEEN FILED / "� :ESSING COFY