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STATE OF CALIFORNIS WATER RESOURCES CONTRIOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE FACILITY/SITE NAME WHERE TANK IS INSTALLED: Q ZE, L 2 h TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY V A. OWNERS TANK ID # n �j B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: ❑ 7 P�RMANENTLY CLOSED TANK L TANK REMOVED �� J �i FARM TANK - YES L_j NO 0 II. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMV 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 ❑ BO EMPTY 2 WASTE7 METHANOL 99 OTHER (DESCRIBE IN ITEM D, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER -NAME O HAZARDOUS SUBSTANCE STORED &C.A.S. # C.A.S. #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY�N BOX A, B, C, A D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3SINGLE WALLEDWI EKTERIORLINER SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAI ENT APPROVED BY NAME ❑ 1 STEELIIRON ❑ 2 STAINLESS STEELK B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNLINED IS LINING MATERIAL COMPATIBLE WITH IW%METHANOL? D. CORROSION ❑ I POLYETHLENEWRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL P PROTECTION ® 5 CATHODIC PROTECTION F-]91 NONE ❑ 95 UNKNOW ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC ❑ 8100% METHANOL COMPATIBLE FRP ❑ 99 OTHER ❑ 4 PHENOUcUNING ❑ 95 UNKNOWN 99 OTHER ❑ 4 FIBERGLASS REINFORCED PLASTIC ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROU D, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRA 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 LINEDT ENCH 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 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD /FRP A U 8 100% METHANOL COMPATIBLE FRP 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 PRI ARY LEAK DETECTION SYSTEM MUST BE CIRCLED. rpss 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRO C MONITOR P S 5 GROUND WATER MONITORING WELLS 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOW P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED (MO/YR) 72TB IMATED QUANTITY OF XMY . WAS TANK FILLED WITH STANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO FGALLO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME (PRINTED & SIGNATURE) DATE LOCAL AGENCY USE ONLY CCOOOUN�TY�# JURISDICTION # AGENCY # EIl� j'`� FACILITY ID # 6 1 1;1 1 y I '_3 / ,TANK ID## CURRENT LOCAL AGENCY FACILI D# APPROVED BY NAME PHONE # WITH AREA CODE PERMIT NUMBER CHECK # I PERMIT AMOUNT FORM B (6-29-88) THIS FORM MUST BE PERMIT APPROVAL DATE V PERMIT EXPIRATION DATE AMT. I FEE CODE I RECEIPT # A FACILITY/SITE APPLICATION, FORM `A', UNLESS A DATA PROCESSING COPY BY: FORMA' HAS BEEN FILED I© C." CV U1 00