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STATE OF CALIFORN' ' WATER RESOURCES CONTRI- OARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION m� COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ro MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ID PERMANENTLY CLOSED o• ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVEDe FACILITY/SITE NAME WHERE TANK IS INSTALLED: 3 5Ff I. TANK DESCRIPTION ,.,...e.r.�....�.._ ._ FARM TANK - YES NO ..-.._.__- A. OWNERS TANK ID # B MANUFACTURED BY: /C C. YEAR INSTALLED ie K D TANK CAPACITY IN GALLONS 1 ' 1119D O TANK CONTENTS or,. . —m A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM _T w- ,v %ti ffh '*mug B. MAIINCU, COMPLETE ITEM D. C. ❑ 1 UNLEADED ❑ 2 LEADED DIESEL F-13 CHEMICAL PRODUCT E]4 OIL P<PRODUCT ❑ 4 GASAHOL E]5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 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 8 CAS. # C.A.S. #: ❑ 3 FIBERGLASS III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN ROY A o e A A TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER S. ❑ I SREUIRON ❑ 2 STMNLESSSTEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIA ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 MINUM ❑ B 100% METHANOL COMPATIBLE FRP A 5 UNKNOWN ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ I RUBBER UNED ❑ 2 ALKYD UNING ❑ 3 EPDXY LINING ❑ 4 PHENOUC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNUNED A 5 UNKNOWN 5 ALUMINUM ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? —ASPHALT ❑ YES [—]NO , '(� OTHER Ll D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TARO ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE1NKNOWN U 99 OTHER ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFAROUFr.RnI1Nn 11 IFIINnForPnllun Anru,c.nn„l... A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY AU 91 NONE U 5 UNKNOWN A U 99 OTHER & CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 5 UNKNOWN A U 99 OTHER RECEIPT # A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 RBERGLASSPIPE A U 91 NONE G MATERIAL A U 5 ALUMINUM A�U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AP./ 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 8 1 VISUALCHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURETESTING 1 NO P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE UST USED (MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH FACILITY ID # D I T 1'/1-51 SUBSTANCE REMAINING IN INERT MATERIAL? ❑ YES ❑ NO I GALLONS PHONE # WITH AREA CODE THIS F( JIM MAO OCCIY UUMrLL I tU UNULK rt NAL I Y OF I'tHJUHIY, AND 1 D I HE BEST OF MY KNOWLEDGE, IS TRUE AND CC APPLICANTS NAME (PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY ?RECT. COUNTY #III 5-7 J��URIIISDI�CTIITION # AGENCY # FACILITY ID # D I T 1'/1-51 TANK ID�# % CURRENT LOCAL AGENCY F�L APPROVED BY NAMEq �o PHONE # WITH AREA CODE PERMIT NUMBER PERMITAPPROVAL DATE PERMIT EXPIRATION DATE CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT # BY: rURM B (s-29-66) INIS rUNM M118I MC AGL:UMPANR,U BY A FACILITT/SITE APPLICATION, rUNM -A', UNLESS A CURRENT FORMA' HAS BEEN RI ED DATA PROCESSING COPY let IC CTI FV F+ N O