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STATE OF CALIFORNF WATER RESOURCES CONTR BOARD FORM B': UNDERGROUND STORAGE TANK PRftRAM TANK TANK PERMIT APPLICATION INFORMATION 49N- t COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK.MARK ONLY ❑ 1 NEW PERMIT ❑X RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOED 10 ONE ITEM ❑ SED TANK ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE B TANK REMOVE FACILITY/SITE NAME WHERE TANK IS INSTALLED: lZOS hl If 3�71 FARM TANK-YES NO ❑ � I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK IDKWi B. MANUFACTURED BY: C. YEAR INSTALLED, D. TANK CAPACITY IN GALLONS. Lam-mo II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 I MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL RODUCT ED 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 NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.K C.A.S.K'. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A. TYPE OF ❑ I DOUBLEWAUED ❑3 SINGLE WALLED WITH EXTERIOR LINER igaUNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CND W/FIBERGLASS REINFORCED PLASTIC B.MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL j�a%UNKNOWN ❑ 99 OTHER C. INTERIOR F11 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED �� UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TARORASPHALT ❑3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE �'g5 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 U 2 PRESSURE A U 3 GRAVITY A U9 NONE A BUS 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 ONE A U 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A k6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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 1VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS S 4ELECTRONIC MONITOR P S SGROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE 8 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY CONTY R JURISDICTION k AGENCY* FACILITY ID K TANK ID R Liurnrn = = 101012EdS 101010111 CURRENT LOCAL AGENCY FACILITY ID K APPROVED BY NAME PHONE N WITH AREA CODE G CN c# /i o PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE I A114 1 CHECK N PERMIT AMOUNT SURCHARGE ANT. FEE CODE RECEIPT N BY: FORM B(6-29-66) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY