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v a V STATE OF CALIFORN1WATER RESOURCES CONTROARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM STA AI V TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FURM WITH TME FULLUWIN16 INFUHMAI IUN FUH EAUM IANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYCLOS K ONE ITEM El INTERIM PERMIT El AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: Q �FARM TANK - YES ❑ NO TANK DESCRIPTIC)N COMPLETE ALL ITEMS -IF UNKNOWN -SO SPECIFY A. OWNERS TANK ID # I B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: S� Q II. 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 PETROLEUMB. / C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL F-]3 CHEMICAL PRODUCT F-]4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL99 OTHER (DESCRIBE IN ITEM D, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF �.i.�^ I% Q]V�,, (� / HAZARDOUS SUBSTANCE STORED & C.A.S. # N C.A.S. #: 'cam I o � / III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D A. TYPE OF ❑ 1 UBLE WALLED F-]3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER A U=95 UNKNOWN A U 99 OTHER ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE INUM ❑ 8100%METHANOL COMPATIBLE FRP MATERIAL [—]9 BRONZE ❑ 10 GALVANIZED STEELNOWN V7A ❑ 99 OTHER A ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 P NOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNLINED 6 CONCRETE 5 UNKNOWN U ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALTV95 WRAP F-14 FIBERGLASS REINFORCED PLASTIC PROTECTION 0 5 CATHODIC PROTECTION ❑ 91 NONE KNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A [6 )1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U=95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 5 UNKNOWN A U 99 OTHER PERMIT NUMBER A U 1 STEEL/IRON 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 AU, 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL All 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. In, om P S 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS �) S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER 7 VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH FACILITY ID # SUBSTANCE REMAINING IN INERT MATERIAL? ❑ YES ❑ NO I GALLONS 161101/P131�? 1 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 # JURISDICTION # AGENCY # FACILITY ID # TANK ID # I E[ 1 161101/P131�? 1 [jojo�l I CURRENT LOCAL AGENCY FACILITY ID # APPROVED BY NAME PHONE #WITH AREA CODE &A 01 CA01130 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK # PERMIT AMOUNT t SURCHARGE AMT. FEE CODE RECEIPT # BY: 4 �, FORM B (6-29-88) THIS FORM MUST BE ANMY A FACILITY/SITE APPLICATION, FORM `A', UNLESS RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY z 1 10 4 W