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STATE OF CALIFORNIA <br /> WATER RESOURCES CONTRO ARD <br /> FORM `B': UNDERGROUND STORAGE TANK PRO AM <br /> TANK TANK PERMIT APPLICATION INFORMATIONm <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING I FORMATION FOR EACH TANK. <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT S CHANGE OF INFORMATION " oN <br /> ONE ITEM 2 INTERIM PERMIT ❑ 7 PERMANENTLY CLOSED TANK <br /> 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED f Z <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: IV <br /> LU. FARM TANK-YES 0 NO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK ID N to <br /> C. YEAR INSTALLED <br /> B. MANUFACTURED BY: LSC G IV <br /> CJ �� D. TANK CAPACITY IN GALLONS: <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D.-Of <br /> �C1 ( / <br /> A. " I MOTOR VEHICLE FUEL � 2 P ROLEUM <br /> B' C. ❑ 1 UNLEADED 0 2 LEADED E]3 DIESEL <br /> 3 CHEMICAL PRODUCT 4 OIL <br /> ❑ 1 P UCT 0 4 GASAHOL E] 5 JET FUEL E]6 AVIATION GAS <br /> 5 HAZARDOUS 80 EMPTY 95 UNKNOWN WASTE Ej 7 METHANOL 9 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.p <br /> .s7e 016 C.A.S.p: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.8 D <br /> A. TYPE OF ❑ 109UBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER <br /> SYSTEM fL�7°/ 0 95 UNKNOWN <br /> SINGLE WALLED �q SECONDARY CONTAINMENT <br /> 99 OTHER <br /> B.TANK <br /> DIS /IRON 2 STAINLESS STEEL 0 3 FIBERGLASS 0 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL L fl CONCRETE 6 POLYVINYLCHLORIDE E] 7 ALUMINUM 8 100%METHANOL COMPATIBLE FRP <br /> E 9 BRONZE El 10 GALVANIZED STEEL E]95 UNKNOWN �99 OTHER <br /> C. INTERIOR El RUBBER LINED E] q qL WING 3 EPDXY LINING 4 PHENOLIC LINING <br /> LINING ❑5 GLASS LINING �—,'6 U/NLINED <br /> 95 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? EjYES E] NO 99 OTHER <br /> D. CORROSION ❑ I POLYETHLENEWRAP 2TAR OR ASPHALT <br /> PROTECTION 5 CATHODIC PROTECTION ❑3 VI AP 0 4 FIBERGLASS REINFORCED PLASTIC <br /> E1 91 NONE 5 UNKNOWN <br /> 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF LINDE OUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U SUCTION A U 2 PRESSURE A GRAVITY <br /> B.CONSTRUCTION A 1 INGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> 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 <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP <br /> A U6100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A095 UNKNOWN <br /> A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 5 <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 91 NONE P S 95 UNKNOWN <br /> P 5 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MO7YB) 2 ESTIMATED QUANTITY OF <br /> SUBSTANCE REMAINING IN 3. WAS TANK FILLED WITH <br /> GALLONS INERT MATERIALP YES E] NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> J� JURISDICTION AGENCY N FACILITY ID N <br /> 3 � TANK ID N <br /> ZE= Ham <br /> CURRENT LOCAL AGENCY FACILITY IDN <br /> S/ APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE1 <br /> P RMIT XPIRATI DATE <br /> CHECK0 PERMIT AMOUNT SURCHARGE AMT. <br /> FEE CODE RECEIPTp BY: <br /> FORMB(6-29-88) THIS FORM MUST BE ACCOMPANI IAFACILITY/SITEAPPLICATION, FORM A%UNLESS RENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />