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STATE OF CALIFORNI. WATER RESOURCES CONTRC IOARD 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 ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL SE K ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED OI FACILITY/SITE NAME WHERE TANK IS INSTALLED: / V 7 1 A.J, TA4 cz 7;F-" 12o4 I It D�' FARM TANK - YES ❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS- IF UNKNOWN_ SO SPFCIFY A. OWNERSTANKID# B. MANUFACTURED BV: C. YEAR INSTALLED /77b D. TANK CAPACITY IN GALLONS'. 60 AID TANK CONTENTS IF (A.1). IS MARKED. COMPLETE ITEM C. IF (A.11. IS NOT MARKED_ COMPLETE ITEM R A- L?fl MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL k1'PRODUCT E:]4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAMEOF HAZARDOUS SUBSTANCE STORED 8 C.A.S. M &ZIA C.A.S. #: Aj A XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, 8 D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM E 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER N OTHER 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8100% METHANOL COMPATIBLE FRP PERMIT EXPIRATION DATE ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER U 3 POLYVINYL CHLORIDE (PVC) ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING EUB'UNUNED U 7 STEEL CLAD W/FRP ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO ❑ 99 OTHER O CORROSIONPROTECTION ❑ OR ASPHALT USS REINFORCED FUSTIC 5 CATHODIC PROTECTION ❑ 91TAR NONE 1:1 95VINYL UNKNOWN ❑ N OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVEGROUND, U IFUNDERGROUND, BOTH IF APPLICABLE 2. ESTIMATED QUA TITV OF A. SYSTEM TYPE A 1 SUCTION A U PRESSURE A U 3 GRAVITY A U N OTHER PHONE # WITH AREA CODE B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U N OTHER DAT PERMIT EXPIRATION DATE A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE C MATERIAL A U 5 ALUMINUM A6 CONCRETE A U 7 STEEL CLAD W/FRP A U B l00% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER . LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR IS FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. -91 P 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING 8 ]PRESSURE TE STING P 8 91 NONE P 8 95 UNKNOWN P 8 W OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED D TE LAST USED (MO/YR) 2. ESTIMATED QUA TITV OF 3. WA TANK FILLED WITH l = SUBSTAN R ING IN ATERIAL? ❑ YES [ NO CURRE T LOCAL AGENCY FACILITY ID # GALLONS APPRCIVED BY AME//�� THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. APPLICANT'S NAME (PRINTED S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # AGENCY # FACILITY ID # TANK ID # l = = ob 1 116 Is IsI I 00 16? CURRE T LOCAL AGENCY FACILITY ID # APPRCIVED BY AME//�� PHONE # WITH AREA CODE RC PERMIT NUMBER PEAPIT APP)ROIJAL DAT PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT CHECK# 7�� SURCHA FAMC FEE CODE RECEIPT# BY: ORM B (3-7-88) THIS FORM MUST BE ACCOMPANIE Y A FACILITY/SITE APPLICATION. FORM W. UNLESS dRRENT FORMA' HAS BEEN FILED '-(7CESSING COPY v t® ca