SITE INFORMATION AND CORRESPONDENCE_FILE 2

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j STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD 1 FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION o COMPLETE A SEPARATE FORM WITH THE FOLLOWINg INFORMATION FOR EACH TANK. z ID MARK ONLY41NITERIMPERMIT NEW PERMIT ❑3 RENEWAL PERMIT^' 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLO K ONE ITEM ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVEDfv 2-J FACILITY/SITE NAME WHERE TANK IS INSTALLED: 22 E / KPS f S?. -irO tgov. ARM TANK-YES NO ry 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY 7 S �� I CD A. OWNERS TANK ID'M I B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Q o O 11. TANK ONTENTS IF(A-1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D A. EV 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM ;�l [:] 1 UNLEADED Ep'2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL PRODUCT 1:14 GASAHOL F-15 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS 80 EMPTY ❑ C.95 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.S.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B.C.A D A.TYPE OF DOUBLE WAILED F-13 SINGLE WADED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 WALED 4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEUIRON ❑2 STAINLESS STEEL r__j 3 FIBERGLASS r__j 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE 6 POLYVINYL CHLORIDE F-1 7 ALUMINUM 8 100%METHANOL COMPATIBLE FRP YATERULL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ R C.INTERIOR F-11 RUBBER UNED [-]2 ALKYD LINING F-13 EPDXY LINING 4 PHENOLIC LINING • ' LINING ❑5 GLASS LINING ❑6 UNLINED 95 UNKNOWW ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO �99 OTHER D.CORROSION ❑ 1 POLYETMLENE WRAP ❑2 TAR OR ASPHALT ❑3 NYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION [:] ❑5 CATHODIC PROTECTION 91 NONE WUNKNOWN ❑99 OTHER IV. PIPING INFORMA ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A kjl SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 5 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U t SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 5 UNKNOWN A U 99 OTHER A U 1 STEELBRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A6 CONCRETE A U 7 STEEL,CLADW/FRP A U 8 100%MUHANOLCOMPATIBLE FRP �'. A U 9 GALVANIZED STEEL A U 85 UNKNOWN A U 99 OTHER LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR 8 FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. / / •i VISUAL CHECK 8 2 INVENTORY RECONCILIATION P S.3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS O P 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P%8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.'WAS TANK FILLED WITH SUBSTANCE REMAINING IN CALL90/6f INERT MATERIAL? I [:]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 M JURISDICTION M AGENCY k FACILITY ID# TANK ID M EU MoiiTl17B iniool CURRENT LOCAL AGENCY FACILITY 10 APPROVED BY NAME PHONE M WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 3-8-g CHECK t PERMIT AMOUNT I "IRCHARGE AMT. FEE CODE SIPT 0 BY: Jw/ v- V.) FORM B(6-29-89) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A CURRENT FORM'A' HAS BEEN FILED __.__.AAT&_PAO.CESSING COPY.s. _ - - -