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STATE OF C+ALIFORNII WATER RESOURCES CONTRO' OARD FORM 'B': UNDERGROUND STORAGE TANK PROC;RAM ,... TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY I✓I ! NEW PERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYCLK ONE ITEM ❑ 2 INTERIM PERMIT [-]4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED IIID' FACILITY/SITE NAME WHERE TANK IS INSTALLED: I S Cl % 1%, j,,& ' 9-fZd I I ^i,[# .FARM TANK -YES ❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. OWNERS TANK ID p 'Zi B. MANUFACTURED BY: ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL C. YEAR INSTALLED Q D. TANK CAPACITY IN GALLONS: ! ::jOCZ II. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED. COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C ❑ 1 UNLEADED 2 LEADED L]3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL E]6 AVIATION GAS ❑ 5 HAZAROOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF �L HAZARDOUS SUBSTANCE STORED 8 CA S A.Sa A CAS. #: A .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D A LE WALLED F-1 3 SINGLE WALLED WrEl LINER 95 UNKNOWN SYSTEM 2SOINGBEWALLEO ❑ 4 SECONDARY CONTAINMENT Ej99OTHER B. CONSTRUCTION 1 STEEL/IRON ❑ 2 STAINLESS STEEL F-13 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK F-15 CONCRETE ❑ 6 POLYVINYLCHLORIDE F -]T ALUMINUM [:]B 100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A U 4 FIBERGLASSPIPE ❑ 1 RUBBERLINED [-]2 ALKYD LINING F-13 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING UNLINED A U B 100% METHANOL COMPATIBLE FRP ❑ 95 UNKNOWN - A ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHUNE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION Pr5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND BOTH IF APPLICABLE A. SYSTEM TYPE A U_ 1 SUCTION A rU72 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A W 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER (/IV// A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U CONCRETE A U 7 STEEL CLAD W/RTP A U B 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A/U/95 UNKNOWN A U 99 OTHER j LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. �1 PS 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P)6 PRECISION TESTIN 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P S N OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DpT LAST USED(MO/YR) 2. ESTIMATEC UANTITYOF 3. WASTAN ILLED WITH CURRENT LOCAL AOENCY FACILITY ID # APPROVED BYAME SUBST R AINING IN IN T E L? YES ❑ NO (/IV// GALLONS THIS FORM -HAS BEEN COMPLFTFO IINOFR PFNAI TY OF PFR.IIIRY ANO TO TNF REST nF MY KNnwl FCW:F IA TRI IF AMID nnRRFCT APPLICANTS NAME (PRINTED 8 SIGNATURE) DATE COUNTY # JURISDICTION # AGENCY # FACILITY ID # TANK IO # 1 bOp CURRENT LOCAL AOENCY FACILITY ID # APPROVED BYAME PHONE # WITH AREA CODE 7L uL, PERMIT NUMBER I P MITARPRPVA-QATE PERMIT EXPIRATION DATE CHECK # PERMIT AMOUNT L,SURCHARGE AMT. I FEE CODE RECEIPT # BY: ORM R (3-7-66) THIS FORM MUST BE ACCOMPANIEESY A FACILITY/SITE APPLICATION. FORM 'A'. UNLESS/1. RENT FORMA' HAS BEEN FILEO DATA PROCESSING COPY w A t S