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OARD STATE OF CALIFORNI. WATER RESOURCES CONTRCSO TANK PROGRAM FORM `B': UNDERGROUND STORAGE TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ❑ 5 CHANGE OF INFORMATION ❑7 P MANENTLY CLOSED TANK 1 NEW PERMIT ❑ 3 RENEWAL PERMIT TANK REMOVED MARK ONLY F-1 ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE w ONE ITEM F-12 INTERIM PERMIT e G2 FARM TANK-YES NO fit} FACILITY/SITE NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY B. MANUFACTURED BY: A. OWNERS TANK ID# D. TANK CAPACITY IN GALLONS: r+2 C. YEAR INSTALLED II. TANK ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITI UNLEADED EM D.LEADED ❑ 3 DIESEL B. C. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS PRODUCT ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) ❑ 5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: HAZARDOUS SUBSTANCE STORED&C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN A.TYPE OF ❑ ❑99 OTHER SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ y BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR ❑6 UNLINED ❑ 95 UNKNOWN LINING ❑ 5 GLASS LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100%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 El95 UNKNOWN El99 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 U 91 NONE A U 95 UNKNOWN !U91 9 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 UNKNOWN9 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLADW/FRPA U 8 100%METHANOL CORP A U 9 GALVANIZED STEEL A U 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. LECTRONIC P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 95EUNKNOWN MONITOR F S 99GOOHERD WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE F3.V/ASTANKFILLEDWITH 2. ESTIMATED QUANTITY OF MATERIAL? 1. ESTIMATED DATE LAST USED(MO/YR) SUBSTANCE REMAINING IN INERT ❑YES E] NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, DGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY TANK ID# COUNTY# JURISDICTION# AGENCY# FACILITY ID# HEI = = I I --� l E= 37 1 APPROVED BY NAME PHONE#WITH AREA CODE CURRENT LOCAL AGENCY FACILITY ID# LZOLLA 0-0 E�Y PERMIT APPROVAL DATE PERMIT EXPIRATIPERMIT NUMBERCHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE FORM `A',UNLESS A RRENT FORMA' HAS BEEN FILED FORM 6(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE DATAPPROCESSING COPY