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STATE OF CALIFORth WATER RESOURCES CONTBOARD FORM `B': UND Df STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOS ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: S Lu, kL Sb c4- � FARM TANK-YES❑ NO Z 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 10 A. OWNERS TANK ID# ' B. MANUFACTURED BY: � C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: I 100 W II. TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A7),IS NOT MARKED,COMPLETE ITEM D. A. ef 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM R. C. �UNLEADED ❑ 2 LEADED ❑ 3 DIESEL F-] 3 CHEMICALPRODUCT E] 4 OIL AJ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL E] 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 90 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAMEOF / ' HAZARDOUS SUBSTANCE STORED&CA.S.# �✓ C.A.S. /4- All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH DGERIOR UNER ❑ 95 UNKNOWN SYSTEM Q 2 SINGLE WAUED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEBUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 LOAMEDIMOL COMPATIBLE FRP MATERIAL MATER ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ 1 RUBBER UNED ❑2',AMOLINING ❑3 EPDXY UNING ❑4 PHENOUC UNING LINING ❑ 5 GLASS UNING 216 UNLINED ❑95 UNKNOWN ❑IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑ TAR OR ASPHALT ❑ 3 WNYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC 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(;1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION AV 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH 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 C.MATERIA A V5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%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 3 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS r P 3 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE- P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE ST USED IMO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH /L SUBSTANCE REMAINING IN / I INERT MATERIAL? ❑YES [:] NO /V GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# ® /1 / y IF I ol o h I / ESI"((3-7-88) ENCY FACILITY ID# APPRpyEp 9Y NAM): �/ PHONE N WITH AREA CODE PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PERMR AMOUNT URCNARGE AMT. FEE CODE RECEIPT# BY: FORM MUST BE ACCOMPANI u BY A FACILITY/SITE APPLICATION, FORM 'A',UNLE RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY