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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FOM `B': UNDERGROUND <br /> TANK TANK PERMIT LI MATION <br /> COMPLETE A SEPARATE FORM 1 TION FOR EACH TANK. z <br /> 10 <br /> AAMC ONLY o 1 NEW POW ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED T <br /> ONE ITEM 2 INTERIM PERMR ❑4 AMENDED KFUT ❑6 TEMPORARY TANK CLOSURE 8 TANK(REI OVED 09 <br /> FACILI*Y/mE NAME wHism TANK N mTAtLED:1130 0 E, FARM TANK-YES❑ NO <br /> I. TANK ASCRIPTION COuPLETE ALL ITEMS-W UNKNom—Bo SPECIFY )tea <br /> ' A OWNERS TANK IDN S. MANUFACTURED BY: 'Ln <br /> C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: OQ 0 <br /> 11. TANK CONTENTS IF(AL1),IS MARKED,COMPLETE mm c.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. ®1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED 3 DIESEL <br /> 3 0 MICAL PRODUCE ❑4 OIL ®1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL 6 AVIATION GAS <br /> 6 HAZAFOOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. F NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&CAS.N C.A.S.N: <br /> 111. TANK CONSTRUCTION MARK ONE tiEM ONLY IN sox A.a C.a D <br /> A.TYPE OF ❑ 1 DOUBLE WAUID 3 SINGLE WALK WITH EXTEROR LINER 95 IINn(mmI <br /> =YETEY ❑2 SNNGLE WALK ❑4 SEC ICIARY CONTANMW ❑99 OTHER <br /> ❑ 1 STEEUTAON ❑2 STAN6.ESS STEEL ❑3 RBERGUISS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC <br /> MATERYIL <br /> L TAM( ❑S CONCRETE ❑6 POLYVINYLCHLORIOE ❑7 A AWIUM E]610014 METHANOL COMPATIBLE FRP <br /> ❑9 BRONZE ❑10 GALVMIZED MR ®95 WNOWN ❑99 OTHER <br /> ❑ 1 RUBBER LNEO ❑2 ALKYD LW ❑3 EPDXY LHW ❑4 PHENOLIC UNlW <br /> LIMO ❑5 GLASSUW4 ❑6 U1i.tINB1 ®95 mm" <br /> ❑ IS LINING MATERIAL CONPARBLE WITH IW%ETHANOL7 ❑YES ❑No ❑99 OTHER <br /> p,( ❑ 1 POLYERLBE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 RBEAGLASS REWDRCEI)PLASTIC <br /> PROTECTION ❑5 cATH00HC PROTECTION ❑91 NONE VI 95 LNNIN" ❑99 OTHER <br /> IV. PIPINGI INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A.rfM TM A to 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> S.COQ 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 <br /> A U i STEEL/RON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C.MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD WlFRP A U 9 10091 METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A�! B5 UNKNOWN <br /> A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> S 1 VISUAL CHECK P S 2 INVENTORY RECONCUATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRS TESTING P S 91 NONE UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1.ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH <br /> TSUBSTANCE REMAINING IN INERT MATERIAL? D YES �NO <br /> GALLONS <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED 6 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> EZ7 <br /> JINUiDICTION# AQENCY# FACILITY ID# TIN(ID# <br /> 10 -10 / $ 1 I 0 0 07 <br /> A004M FACMJTY ID I APPROVED AY NAME PHONEiW"AREACODEPERIUT APPRVAL DATEPERMIT EXPIRATION DATLP§r&W AYOUNT - SURG4AROE AMT. FEE CODE 'RECEIPT•I 1 SY: <br /> Fame*" pwr arjk*=jftxM "jcATlOK FORM'A'L tAlt-—W <br /> FEIN A' "woman <br />