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STATE OF CALIFORNI WATER RESOURCES CONTR 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 NEWPERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ® 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE u 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED:"0 ?U1LD Z O 5 FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY E A. OWNERS TANK IDR 0 -2- B. MANUFACTURED BY: ulyKovjA.) O YEAR INSTALLED t D. TANK CAPACITY IN GALLONS: ie (A) IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. lj A. ® 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM8. C. ® 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL N j ❑3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑60 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.R C.A.S.W MI.I. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.8,C,8 D A. TYPE OF ❑ 1 DOUBLE WAILED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ®2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ® I STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK -1 5 CONCRETE 6 POI CHLORIDE ❑7 ALUMINUM ❑ B 10D%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC UNING C. INTERIOR LINING F-] 5 GLASS LINING ❑6 UNLINED ®95 UNKNOWN ❑LSUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION I POLYETHLENEWRAP ®2 TAR OR ASPHALT J❑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 IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A Q 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER AUO1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%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 J�:)1 VISUAL CHECK P ®2 INVENTORY RECONCILIATION P B 3 VACOSE WELLS P 8 4 ELECTRONIC MONITOR (D S 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/VR) 2. ESTIMATED QUANTITY OP 3.WAS TANK FILLED WITH j 14pr, SUBSTANCE REMAINING IN 6 GALLONS INERT MATERIAL? ®YES ❑ NO j THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJU ND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'SNAM WNTED&SIGNATURE) DATE mh -kF Lola LOCAL AGENCY USE ONLY COUNTY N JURISDICTION R AGENCY R FACILITY ID R TANK ID# m CURRENT LOCAL AGENCY FACILITY ID b APPROVED BY NAME PHONEM WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT• BY: FORM B(3-7-66) THIS FORM MUST BE ACCOMPANP:`SCY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS AtORENT FORMA' HAS BEEN FILED "ESSING COPY