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STATE OF CALIFORNIft WATER RESOURCES CONTROWARD FORM 'B': UNDE GROUND STORAGE TANK PRO AM TANK TANK PERMIT APPLICATION INFORMATION (az COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 1O MARK ONLY ❑ 1 NEW PERMIT F� 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSUREANK REMOVED ('9 N FACILITY/SITE NAME WHERE TANK IS INSTALLED: c , FARM TANK-YES❑ NO .16 CTI 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK IDUI-A B. MANUFACTURED BY: LAX -4 C YEAR INSTALLED i I KI, D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 'lMOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. [:] 1 UNLEADED ❑2 LEADED ❑3 DIESEL F-13 CHEMICAL PRODUCT ❑ 4 OIL B. 1 PRODUCT E]4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ©-95'OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF 4 HAZARDOUS SUBSTANCE STORED&C.A.S.# I�1._� C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/RBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑8108%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEELKNOWN ❑99 OTHER F-] 1 RUBBERLINED ❑ 2 ALKYD LINING F-13 EPDXY LINING ❑ 4.PHENOLIC LINING C. INTERIOR LINING 5 GLASSUNING 6 UNLINED KNOWN❑ ❑ ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL9 ❑YES ❑NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONEWN ❑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 2PRESSURE A U 3 GRAVITY A U 91 NONE A U 35 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 Y5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 10D%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 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. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 7; 1. ESTIMATED Q,TE LAST USED(MO/VR) 2. ESTIMATED OUANTITY OF F 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS I INERT MATERIAL? ❑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) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY IDM [y'�� / ,TTAANK ID# CURRENT LOCAL AGENCY F,ILID#� ' APPR01[EO%l NAME PHONE#WITH AREA CODE PERMIT NUMBER S PERMIT APPROVAL DATE(/Y'lilJ1 PERMIT EXPIRATION DATE CHECK# PERMITAMOUNT SURCHARGE AMT. FEE CODE RECEIPT k BY: FORM B S-29-68) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY