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STATE OF CALIFORN WATER RESOURCESCONTROVDARD FORM B': UNDERGROUND STORAGE TANK PROGRAM ` TANK Z-- TANK PERMIT APPLICATION INFORMATION ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANN) MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION7 PERMANENTLY CL ONE ITEM 2 INTERIM PERMIT A AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE S TAW REMOVED D FACILITY/URE NAME WHERE TANK IS INSTALLED: - FARM TANK•YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS•IFUNKNOWN-80SPECIFY 9�zO A OWNERS TANK ID N B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TA14KCONTENTS IF(A.I),15 MARKED,COMPLETE ITEM C.IF IRA).IS NOT MARKED,COMPLETE REM D. A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. 1 UNLEADED ❑2 LEADED 3 DIESEL 3 CHEMICAL PRODUCT A OIL 1 PRODUCT A GASOHOL ❑5 JET FUEL ❑6 AVIATION GAS 5 HAZARDOUS ❑ BD EMPTY ❑95 UNKNOWN ❑Z WASTE ❑7 METHANOL 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 C.A.S.N C.A.S.N'. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN SOS A.B,C.A D A TYPE OF ❑ I oDwwALLED ❑3 SINGLE WALLED WITH EVTERIOR LINER 95LWNOW4 SYSTEM IIIA❑MMAx-�Y11I 2 SINGLE WALLED ❑A SECONDARY CONTAIN AEM N OTHER B.TANK IJ I STEBURON 2STAINLESS STEEL ❑ UD 3FIBERGLSS 1STEEL CW/RBERGUSS REINFORCED PLASTIC MATERIAL5 CONCRETE ❑6 POLYVINYL CHLORIDE 7 ALUMIMIM ❑B 10016 METHANOL COMPATIBLE FRP 9 BRONZE ❑10 GALVANIZED$tEEI ❑95 UNKNOWN ❑99 OTHER ERIOR F-11 K BERUNED E]2 ALM UNING [j3 EPDXY LINING n 1 PHENDUC LINING C.INT LINING ❑5 GLASS LINING 1:16 UNLINED 95 UNKNOWN ❑G LINING MATERIAL COMPATIBLE WITH 10011 METHANOL' ❑YES ❑NO 99 OTHER D.CORROSION ❑ I POLYETHLEN WRAP ❑2 TAR OR ASPHALT 3VINY1 WRAP ❑1 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION 91 NONE �%UNKNOWN ❑R OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE 5aM UNKNOWN A U "OTHER B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE AV 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U A FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 9 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 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 t I VISUAL CHECK P t 2 INVENTORYRECONCILIATION P t 3 VADOSE WELLS P t A ELECTRONIC MONITOR P t s GROUND WATER MONITORING WELLS • t 6 PRECISION TES TING P S 7 PRESSURE TESTING P t 91 NONE 95 UNKNOWN P t MOTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1 ESTIMATED DATE LAST USED MO/YR) 2. ESTIMATED QUANTITY OFOAGALLONS3.WAS TANK FILLED WITH 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. APPLICANT'S NAME(PRINTED 6 SIGNA EI DATE 1 Las LOCAL AGENCY USE ONLY COUNTY t JURISDICTION I AGENCY F FACILITY ID F TANK ID t ® = = I dG 23 000z � CURRENT LOCK AGENCY FA[f�i,IIT LT ID N APPROYEO AY KAM PHOW a WITH AREA CODE / / PGYR MUMtER PERYR APPROVAL DATE PERMIT[KPNUTION DATE cmcx F PEAMR AMOUNT SURCHARGE ANT. KE CODE RECENTE SY: \ \ FORM aN-z9-661 TNM FORM MUST BEA000WAN1"T A FACERTIMIE APPMTIO4 FORM'A',IINU136 A C- '9R PM IN IMS BEER FEED 1 DATA liftCESSING COPY 2 LOCAL AGENCY COPE -9 FRE COPY