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STATE OF CALIFORNI& WATER RESOURCES CONTR�OARD FORM `B': UND ROUND STORAGE TANK - AM TANK COMPLETE PERMIT APPLICATION INFORMATION A SPPAPATP FnAM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT `(CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED ISIS FACILITY/SITE NAME WHERE TANK IS INSTALLED: � a 3 Q Was ' - [m FARM TANK - YES [_1 No u SPECIFY ANKLprSCRII-Num COMPLETE ALL ITEMS-.. ...•.•••.. •••• S --O S -'--- A OWNERS TANK ID # B. MANUFACTURED BY'. C YEAR INSTALLED D TANK CAPACITY IN GALLONS: 14000 TANK%;UN I CN 1a Ir IA.IJ, IJ MAA.... {.VM.LC,G ••gym v. .. \^'•/.• ' A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL F-13 CHEMICAL PRODUCT F -]B 4 OIL 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 C.A.S. #: HAZARDOUS SUBSTANCE STORED & CA S. # III. TANK C0N5THUuIIuN MARKONEITEMUNLTINPVAA,P,Y,P.. IV enou ATll1M 11.11 1A Rnpnwp r.Rnl Wn U IF I INDERGROUND. BOTH IF APPLICABLE V. t:k5 VI. A SYSTEM TYPE A U 1 SUCTION AOQ PRESSURE A A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER NONE E?ISTEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 6 10096 METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING Fe5 UNKNOWN ❑ 5 GLASS LINING ❑ 6 UNLINED LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑YES ❑ NO ❑ ''OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP M4511UNKNOWN ❑ 4 FIBERGLASS REINFORCED PLASTIC ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE IV enou ATll1M 11.11 1A Rnpnwp r.Rnl Wn U IF I INDERGROUND. BOTH IF APPLICABLE V. t:k5 VI. A SYSTEM TYPE A U 1 SUCTION AOQ PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A 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 STEEL/IRON C. MATERIAL A 5 ALUMINUM'- A A U 2 STAINLESSSTEEL U 6 CONCRETE A A U 3 POLYVINYL CHLORIDE(PVC) U 7 STEEL CLAD W/FRP A U A U 4 FIBERGLASS PIPE A U 91 NONE 8 100% METHANOL COMPATIBLE FRP PERMIT APPROVAL D A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER FEE CODE RECEIPT M AOL r w v mere TVI KI CVSTCM r,orl R P FnR PRIMARY OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MU5I OI: clna.�Pl+. P S 1 VISUAL CHECK ® S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER 1010^011U lnu nu TANK PERMANENTLY CLOSED IN PLACE N1. �ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH NO V / T SUBSTANCE REMAINING IN INERT MATERIAL' ❑ YES ❑ nGALLONS THIS FCI 'A n nrrAl rnA.fo1 rrcn I imnF0 PrAw TV nF PE-RADHY. AND I U I Eft 01=0 I yr "I, nlvv APPLICANT'S NAME (PRINTED 6 SIGNATURE) DATE Y LUL:AL AUCNL.Y USE ONL COUNTY # JURISDICTION # AGENCY # FACILITY ID # o b/I TANK ID # o 00 CURRENT LO AL AGENCY FACILITY ID # APPROV PHONE # WITN AREA CODE 3D, 1 r� PERMIT NUMBER PERMIT APPROVAL D PERMIT EXPIRATION DATE CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT M AOL BY: FORMB(6-29-BB) THIS FORM MUST BE ACCOMPANIEUIrrA PACILI I TI511E ArmlbAUVR, rvnm n DATA PROCESSING COPY o� CA) W OD 0