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STATE OF CALIFORS WATER RESOURCES CONTRIOARD T FORM B': U-14DERGROUND STORAGE TANK PROGRAM S " TANKTANK PERMIT APPLICATION INFORMATION a COMPLE)•E A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - MARK ONLY 1 NEVI PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT F-1 A AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE B TANK REMOVED rol FACILFTY/SITE NAME WHF!{E TANK IS INSTALLED: FARM TANK•YES❑ NO l � I. TAW.K DESCRIPTION COMPLETE ALL ITEMS•IF UNKNOWN-90 SPECIFY A OWNEY"+S.,T„ANKID'N ITNKNOWN B. MANUFACTURED BY: OWEN LORNING C YEAR INSTALLED 1 99f1 O. TANK CAPACITY IN GALLONS: 12,000 I 11. TANK CONTENTS IF(AI),IS MARKED,COMPLETE ITEM C.IF(A.I),IS NOT MARKED,COMPLETE ITEM D. A. ff I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED [a 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL 0 1 PRODUCT ❑N GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ SO 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 6 C A.S.N CA S N: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN SOX A,B.C.A D A TYPE OF 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER %UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑A SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEL/IRON ❑2 STAINLESS STEEL ®3 FIBERGLASS ❑,STEEL CLAD W/FIRE PLAZI B.TANK MATERIAL ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑B 100%METHANOL c1 fl ❑9 BRONZE ❑ 10 GLLVANIZFD STEEL ❑%UNKNOWN ❑%OTHER Y� m., F-] 1 RUBBER LINED ❑2 ALIMIUNING ❑ 3 EPDXY LINING [3K RIENOLICUNING 9 101.9 C'LINNGR ® sGussuMNc E16 UNLINED ❑%LMKNO%N ENVIRONMENTAL HEALTH ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPKkLT ❑3'AWL WRAP ❑A FIBERGLASSREINFORCIDPJSTIC PROTECTION ❑ 5 CATHODIC PROTECTION ®91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE 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 W OTHER S. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U M UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U A FIBERI PIPE A U 91 NONE C.MATERIAL A U 5ALUMINUM A U 6CONCRETE A Al 7STEEL CLAD W/FRP A U 8100%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 PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. • t 1 VISUAL CHECK • t 2 INVENTORY RECONCILIATION P t 3 VAOOSE WELLS O t A ELECTRONIC MONITOR P t s GROUND WATER MONITORING WELLS • 6 PRECISION TESTING P t 7 PRESSURE TESTING • t 91 NONE P t 95 UNKNOWN P t %OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I ESTIMATED OATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH N/A SUBSTANCE REMAINING IN N/A OALLONt INERT MATERIAL.N/A []YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) / A ^ DATE HELEN LORE'. V✓( 0 LOCAL AGENCY USE ONLY COUNTY E JURISDICTION E AGENCY t FACILITY ID E TANK ID t UI�l FM = .10001,3_ �) CURRENT AGENCY FACILITY ID N APPROVED BYNAME �yJ PHONE 0 WITH AREA CODE L - a_ I n PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE �l \ CHECKS PERMIT AMOUNT SURCHARGE AMT. ME CODE RECEIPT0 BY: FORM B(6-29-86) THIS FORM MUST SE ACCOIMAM IIV A FACEmmm APPMTION, FORM'A',LKM A CMMKT FM'A' NAS SEEN FILED \ �1J 1 DATI&CESSING COPY 2 LOCAL AGENCY COPla FEE COPY