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STATE OF CALIFOF WATER RESOURCES CONTR CARD <br /> FORM `B': UND <br /> ERGROUND STORAGE TANK PROGRAM �o <br /> TANK PERMIT APPLICATION INFORMATION <br /> TANK 'S <br /> CO LETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 RMANENTLY CLOSED TANK <br /> ONE ITEM El 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE L4r TANK REMOVED 6' oor <br /> /_ - FARM TANK-YES L] NO s O <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: Ila (L <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY <br /> A. OWNERS TANK ID Al B. MANUFACTURED BY: �i <br /> C. YEAR INSTALLED <br /> D TANK CAPACITY IN GALLONS: CQ e9l <br /> 11. TANK CpfITENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> C. 1 UNLEADED ❑ 2 LEADED <br /> A. 1 MOTOR VEHICLE FUEL 2 PETROLEUM V1PRODUCT <br /> IESEL <br /> 3 CHEMICAL PRODUCT F--] 4 OIL <br /> 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 2 WASTE 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> Q 5 HAZARDOUS 1:1 BC EMPTY D 95 UNKNOWN <br /> D. IF NOT MOTOR VEHICLE F EL,ENTER NAME OF C.A.S.#: <br /> HAZARDOUS SUBSTANCE TORED&C.A.S.# <br /> III. TANK CONSTRUCTIO MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF ❑ 1 DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER El 95 UNKNOWN <br /> SYSTEM ❑2 SINGLE WALLED F-1 4 SECONDARY CONTAINMENT ❑ 99 OTHER <br /> 1 STEELPRON 2 STAINLESS STEEL El 3 FIBERGLASS 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC <br /> B.TANK ❑ 5 CONCRETE POLYVINYLCHLORIDE 7 ALUMINUM B 100%METHANOL COMPATIBLE FRP <br /> MATERIAL 9 BRONZE F--] 10 ALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED F-1 2 ALKY INING 3 EPDXY LINING 0 4 PHENOLIC LINING <br /> C. INTERIOR F-�5 GLASS LINING F-1 6 UNLINED El 95 UNKNOWN <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE OTH100%METHA OL? YES Q NO 99 OTHER <br /> D. CORROSION [:jI POLYETHLENE WRAP F—] 2 TAR 09 ASPHALT 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION D 5 CATHODIC PROTECTION [:]91 NONE fl 95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U\UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IHON A U 2 STAINLESS STEEL A 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100'%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECON RY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S ELECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 NKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED,IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE:REMAINING IN INERT MATERIAL? YES fl NO <br /> GALL NS <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF Y KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> Ll I I roQA / 1316 10V)lol (oll <br /> CURRENT LOCAL AG NCY FACT IDR - APPROV BY AME PHONE#WITH AREA CODE <br /> .L� <br /> PERMIT NUMBER PERMIT APPROV L PERMIT EXPIRATION DATE/'� <br /> aV <br /> CHECK# PERMIT AMOUNT jjLRCHARG AMT. FEE CODE R EIPT# BY: <br /> FORM B{s-29-69) THIS FORM MUST BE ACCOMPANIED 8Y A FAC DATA <br /> APPLICATION, FORM 'A',UNLESS A CURRENT FORM`A' NAS BEEN FILED <br /> DATA PROCESSING COPY <br />