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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `B': UNDERGROUND STORAGE TA PROGRAM ? ° TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY F-11 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E] 7 PERMANENTLY CLOSED TANK ❑6 TEMPORARY TANK CLOSURE �' ANK REMOVEDcq DO ONE ITEM F-12 INTERIM PERMIT ❑ 4 AMENDED PERMIT ff c� (- .-, FARM TANK-YES❑ NO � FACILITY/SITE NAME WHERE TANK IS INSTALLED: L-1 nC1 � I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY -4 A. OWNERS TANK ID If B. MANUFACTURED BY: D. TANK CAPACITY IN GALLONS: l�JU C. YEAR INSTALLED II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NO 7 MARKED,COMPLETE ITEM D. ESEL B C. ❑ 1 UNLEADED ❑ 2 LEADED A. 1 MOTOR VEHICLE FUEL F-] 2 PETROLEUM E] 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWNPEO 2 WASTE ❑ 7 METHANOL 99 OTHER(DESCRIBE IN ITEM BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.4: HAZARDOUS SUBSTANCE STORED&C.A.S.N III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLEWALLED Ej 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK F-�5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL 2-9SUNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS UNING ❑ 6 UNLINED -E7�95 UNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? E]YES ❑ NO THER D.CORROSION ❑ I POLYETHLENEWRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONEUNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE EMMATERIALfA M TYPE U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER RUU 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U UNKNOWN A U 99 OTHER U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE U 5 ALUMINUM A�CONCRETE A U 7STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP U 9 GALVANIZED STEEL A U 5 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 S 1VISUALCHECK P S 21NVENTORV RECONCILIATIONS 3VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 5 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3,WAS TANK FILLED WITH 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN GALLONS INERT MATERIAL' ❑YES [:] NO �- THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. DATE APPLICANT'S NAME(PRINTED&SIGNATURE) _ LOCAL AGENCY USE ONLY COUNTY N JURISDICTION k AGENCY# FACILITY ID R TANK ID R ® a l 3 o= APPROVE BY NAM ` PHONE Y WITH AREA CODE CURRENT LOCAL AGENCY FACILITY ID M� � I PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECKN PERMIT AMOUNT RCHARGE AMT. FEE CODE RECEIPT% BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITYDATAPPROCION NOROM A',UNLESS A RRENT FORMA' HAS BEEN FILED