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STATE OF CALIFORIfl WATER RESOURCES CONT OARD FORM 'B': UNbr-RGROUND STORAGE TANK P b4rFR A M TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY F-1 1 NEW PERMIT F-1 3 RENEWAL PERMIT & CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE Ej B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: L/O t5--, /-1 '4'� ��-7 ARM TANK-YES 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 10 A. OWNERS TANK ID It B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TAN_ Kp6NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A-1),IS NOT MARKED,COMPLETE ITEM D. 00 A. g 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. 1 UNLEADED ❑ 2 LEADED EK3 DIESEL F-� lum 3 CHEMICAL ❑ 4 OIL V, PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS El 5 HAZARDOUS ❑ 80 EMPTY [:] 95 UNKNOWN ❑ 2 WASTE 1:17METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: HAZARDOUS SUBSTANCE STORED&C.A.S.# xill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF r--j 1 DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINEA ❑ 95 UNKNOWN SYSTEM rZ"2`SINGLE WALLED 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEL/IRON F—]2 STAINLESS STEEL E] 3 FIBERGLASS ❑4 STEEL CLAD WIF19ERGLASS REINFORCED PLASTiC B.TANK E] 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 ION METHANOL COMPATIBLE FRP MATERIAL D 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER F-11 RUBBER LINED Ej 2 ALKYD LINING ❑3 EPDXY LINING ENOLIC LINING C. INTERIOR LINING F—] 5 GtASS LINING F—] 6 UNLINED V�5 UNKNOWN F-1 ISLINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES 0 NO El 99 OTHER D.CORROSION F-1 1 PoiyETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 0 5 CATHODIC PROTECTION ❑91 NONE RZ95 UNKNOWN Ej 99 OTHER IV. PIPING INFO RMATjON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A(U)i SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER 4 () B. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORDE(PVC) A U 4 FIBERGLASS PIPE C.MATERIAL A U 5 ALUMINUM6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL ;�fU95 UNKNOWN A U 99 OTHER V. AK DETECTIO Y$TEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST B8 CIRCLED. P 1 VISUAL CHECK P S 2 INVENTORY RECdNCILIATION P S 3 VADOSE WELLS P 5 4 ELECTRONIC MONITOR P S -S-GRDUND WRTER MDNITSRING WELLS V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE T- FILLEC WITH 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANT17Y OF 3WAS TANK SUBSTANCE REMAINING IN INERT MATE�RIAL-? YES ES [0:] NO I GALLONS 0 THIS Fopm HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S LICANT'S NAME{PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY FCOUNTY# JURISDICTION# AGIENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT 0 BY: FORM 6(3-7-88) THIS FORM MUST BE ACCOMPANIEu df A FACILITY/SITE APPLICATION, FORM 'A,UNLESS A..AAENT FORMA' HAS BEEN FILED DATA PROCESSING COPY