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STATE OF CALIFORNIO WATER RESOURCES CONTR*OARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK7 TANK PERMIT APPLICATION INFORMATION .A ° v COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. G MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION " t ONE ITEM ❑2 INTERIM PERMIT ❑ 7 PERMANENTLY C K ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: l2LJE, Nl. E-T T &A TANK-YES❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 9S 7.01 A. OWNERS TANK ID# �. (� B. MANUFACTURED BY. (A C. YEAR INSTALLED 6-1 D. TANK CAPACITY IN GALLONS: Q(�V If. TANK CONTENTS IF(A.1 IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL 2 PETROLEUM B C. ❑ 1 UNLEADED ❑2 LEADED 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL �pRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAB ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ g5 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.# C.A.B.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF �T DOUBLE WALLED ❑ 3 SINGLE WALLED WITH DRERIOR LINER ❑ 95 UNKNOWN SYSTEM FLTyJI 2 INGLEWALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER B. TANK I STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑61W%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ ID GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2ALKYD LINING 3 EPDXY LINING ❑ ❑95 HENOUCUNKNOW LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED ILS-�1/ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLEWITH IW%METHANOL? ❑YES 0N V9s OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT 3 LWRAP PROTECTION ❑ 4 FIBERGLASS REINFORCED PLASTIC ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORM! ION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVDV q U 91 NONE A U 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 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS-PIPE U 91 NONE C.MATERIAL A U SALUMINUM A 6 CONCRETE A U 9GALVANIZED STEEL AlU 95 UNKNOWN A U ]STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM P 3 1 VISUAL CHECK MUST BE CIRCLED, P 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 VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L EBTIMATEO DATE LAST USED(Muff") 2. ESTIMATED GUANTITY OF SUBSTANCE REMAINING IN 3. WAS TANK FILLED WITH GALLONS INERT MATERIALS ❑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 R JURISDICTION# AGENCY# FACILITY ID M ® Cm ' D TANK ID# CURRENT LOCAL AGENCY FACILITY k � O O Q I �^ APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE QQ CHECK# PERMIT AMOUNT SURCHARGE AMT. 3�V FEE CODE CEIPT# BY:1 n , FORMB(6-29-8s) THIS FORM MUST BE ACCOMPANIED BYA FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HASBEENFILEDINI4L/• DATA PROCESSING COPY