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STATE OF CALIFORNIAL„1 NATER RESOURCES CONTROL�� LRD FORM `B': UNDERGROUND STORAGE TANK PROGRAM LZO K TANK PERMIT APPLICATION INFORMATION COMP E A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 4� ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK NEW PERMIT ❑ 3 RENEWAL PERMIT ❑g TANK REMOVED 'v ❑q AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 1NTERIM PERMIT FARM TANK-YES❑ NO Ab E TANK IS INSTALLED: 00 -4 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY (� B. MANUFACTURED By A. OWNERS TANK IDN D. TANK CAPACITY IN GALLONS'. C. YEAR INSTALLED II.nHAZARDOUS ENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT M77P7 COMPLETE EADED ESEL B. VEHICLE FUEL ❑ 2 PETROLEUM RODUCT ET FUEL ❑6 AVIATION GAS AL PRODUCT ❑ 4 OIL OTHER(DESCRIBE IN ITEM D,BELOW) OUS 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE R VEHICLE FUEL,ENTER NAME OF S.N' UBSTANCE STORED&C A.S.N Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER �95 UNKNOWN SYSTEM �,8'SINGLE WALLED ❑ 45ECONDARY CONTAINMENT ❑99OTHER 1 STEELPRON ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE F-] 6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL F-1 9 BRONZE 10 GALVANIZED STEEL ❑95 UNKNOWN M OTHER ❑ 2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING ❑ 1 RUBBER LINED ❑g5 UNKNOWN C.INFERIOR ❑5 GLASS LINING UNLINED LINING ❑ IS LINING MATERIALCOMPATIBLE WITH 100%METHANOL? YES EL ] 990THER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TAR RASPHALT 3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 1 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE EC. MATERIAL SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER RUCTION A 1 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 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL 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. p g 1VISUAL CHECK P S 21NVENTORY RECONCILIATION P S 3VADOSE WELLS P S 4ELECTRONIC MONITOR P S SGROUND WATER MONITORING WELLS" P 8 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 3.wnsTANK Flueo WITH 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF INERT MATERIAL? ❑YES E] NO SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. DATE APPLICANT'S NAME(PRINTED 6 SIGNATURE) LOCAL AGENCY USE ONLY FACILITY IDTANK ID N I� C��OUTIN�T–Y�/M �I JURISDICTION N AGENCY% M APPROVE YNAME PHONE N WITH AREA CODE CURRENT LOCAL AGENCY FACILITY IDN / PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION D TE ECKM PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTN BY: CN FORM B(6-29-86) THIS FORM MUST BE ACCOMPANIE A FACILITYD I TA AAPPLI OAC ON, FORM COPY A',UNLESS A` RENT FORMA' HAS BEEN FILED