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STATE OF CALIFCRIM WATER RESOURCES CONT 900ARD FORM `B': UNDERGROUND STORAGE TANK PR GRAM TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWIN INFORMATION FOR EACH TANK. MARK ONLY F—] 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED T K ONE ITEM El INTERIM PERMIT El AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 1 n� FACILITY/SITE NAME WHERE TANK IS INSTALLED: ��U Y (r j NFARM TANK-YES❑ NO ^ 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OVVNERS TANK ID# B. MANUFACTURED BY: �'j �7 � C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 7y U'/ II. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,C PLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED [:] 2 LEADED ❑ 3 DIESEL F—] 3 CHEMICAL PRODUCT F—] 4 OIL L_J " PRODUCT ❑ 4 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&C.A.S.q C.A.S 11', 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&0 A.TYPE OF _ DOUBLE WALLED F__] 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEL/IRON ❑ 2 STAINLESSSTEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ B 1 DO%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER F-11 RUBBER LINED E] 2 ALKYD LINING ❑ 3 EPDXY LINING A PAENOLIC LINING C. INTERIOR 5 GLASS LINING 6 UNLINED 95 UNKNOWN LINING ❑ ❑ ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYEfHLENEWRAP ❑ 2 TAR OR ASPHALT 03 ,P'rYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑ 91 NONE Dr9595 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF AB VE GROUND, U IF UNDERGROUND,BOTH 1F APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A(Uj 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 95 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 NONE A(U)95 UNKNOWN A U 99 OTHER A U 1 STEELIIRON 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 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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. Q S i VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S I ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S I PREGISIONTESTIN 5 7 PRESSURETESTING P S 91 NO P 5 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF =INERT FILLED WITH SUBSTANCE REMAINING IN ERIAL? ❑YES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY IF :LOCAL JURISDICTION# AGENCY# FACILITY ID# TANK ID# / ! Z- o U AGENCY FACILITY ID# APPROVV/ED BYM,, PHONE#WITH AREA CODELAI PERMIT APPROVAL DATE PERMIT EXPIRATIO DATE PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM `A' UNLESS A - RENT FORM"A' HAS BEEN FILED f 8-29-88) THIS FORM MUST BE ACGOMPANI A FACILITYlSiTE APPLICATION, , DATA PROCESSING COPY