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STATE OF CALIFOP#A WATER RESOURCES CO L BOARD FORM 'B': UNDERGROUND STORAGE TANK GRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY❑ NEWPERMIT ❑ 3 RENEWAL PERMIT IrCHANGE OF INFORMATION F-]7 PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT , 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED 0 -Z- FACILITY/SITE NAME WHERE TANK IS INSTALLED: 7 SW CU LUNG(. tmac/ FARM TANK - YES ❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID # 2/ B. MANUFACTURED BY'. C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 7,.tC7 - II. TANK CONTENTS IF (A.1), IS MARKED. COMPLETE ITEM C. IF (A.11. IS NOT MARKFn CnMPI FTP ITFM n A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL ❑ 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 0, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF N A CA S, #: ✓✓ Q HAZARDOUS SUBSTANCE STORED & C.A.S. # Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D A. TYPE OF ❑ 1 ONUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER F-195 UNKNOWN SYSTEM 2 SIGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER SUCTION `❑✓ 1�STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE FRP A U ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR F -11:1i RUBBER LINED 2 ALKYD LINING F-13 EPDXY LINING 1:14 PHENOLIC LINING LINING ❑ 5 GLASS LINING ff6 UNLINED 4 FIBERGLASS PIPE ❑ 95 UNKNOWN C. MATERIAL ❑ IS LINING MATERIAL COMPATIBLEWITH 10096 METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER IVnmwi. • ••-••�.... �....,,-... JURISDICTION# .. c w i �VnUUrvU, V rUlNUtNkPhUUNU,BV I 1111-APPLICABLEA. TANKID# CURRENT LOCAL AGENCY FACILITY ID S SYSTEM TYPE A U_1 SUCTION A U PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM A J1�6 CONCRETE A U 7STEEL CLAD W/FRP A U 8100% METHANOL COMPATIBLE ERR A U 9 GALVANIZED STEEL ^�L/•yf 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, J P 8 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P �6 PRECISION TESTING P S 7 PRESSURE TE STING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED ATE LAST USED (MO/VRI 2. ESTIMATED OUAN TY OF 3. WAS A SUBSTANCE N GIN IN ' GALLONS THIS FO M HAS BEEN COMPLETED UNDER PENALTY OFPERJURY. AND TO THE BEST OF MY KNOWLI APPLICANTS NAME (PRINTED S SIGNATURE) DATE LOCAL AGENCY HSE ANL Y ❑ YES ❑ NO IS TRUE AND CORRECT. COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANKID# CURRENT LOCAL AGENCY FACILITY ID S APPROVED BY NAME , (p PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PER IT EX IRATION DATE CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT M By; -�� ..•.,,.�..,,, ucnwv.nrnmFv of wrwuul ❑JILL APPLIN111UN, rvnm At, UNLESS A-UURRENT FORMA' HASBEENFILED DATA PROCESSING COPY z :G