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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 4B': I UNDERGROUND STORAGE TANK PROGRAM \/ as TANK TANK PERMIT APPLICATION INFORMATION OMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ® :a� MARK ONLY ^ NEW PERMIT F-13 RENEWAL PERMIT CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM 2 TERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑6 TANK REMOV 2 a- FACIUTY/SITE NAME WHERE 4ANK IS INSTALLED 3 Lt/. T K-YES❑ NO z 1. TANK DESCRIPTION C PLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY I A. OWNERS TANK ID N L1ti B. MANUFACTURED BY: UN C.YEAR INSTALLED �. D. TANK CAPACITY IN GALLONS: ' OOV W 11. TANK C ENTS IF(A.1),1 ARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. M A. P�rl'MOTOR VEHICLE FUEL ❑ 2 PETFI B.EUM C. ❑ 1 UNLEADED ❑ 2 LEADED DIESEL ca ❑3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY 95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN REM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME 6f I HAZARDOUS SUBSTANCE STORED 8 C.A.S.R / /1✓ ,09- C.A.S.B: - KIII. TANK CONSTRUCTION MARK 6vE ITEM ONLY IN BOX A,B,C,A D A TYPE OF ❑ t AUFD F-] 3 SING WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SINGLEWAUED ❑4 SECO RYCONTAINMENT ❑99 OTHER DIIS�TERJIRON ❑2 STAIN EL ❑3 FIBERGLASS ❑4 MEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TAMC ❑ 5( ❑6 POLYVINYL on ❑ 7 ALUMINUM ❑ 6100A METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED EL ❑ 95 UNKNOWN ❑ 99 OTHER F-11 RUBBERUNED ❑2 ALKYD LINING 3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR LINING ❑5 GLASS LININGNLINED �95 UNKNOWN ❑IS UMNG MATERIAL COMPATIBLE WITH 1 ETHANO .` YES ❑99 OTHER D. CORROSION ❑I POLYETHLENE WRAP [alTAR OR ASPHALT 3 WNYLWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHOOICPROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF NDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 0 SUCTION A U 2 PRESSUREU 3 GRAVITY A U 99 OTHER A B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED 3 LINED TRENCH A QjUNKNOWN A U %OTHER A U i STEEL/IRON A U 2 STAINLESS STEEL A 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A UX STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 1995 UNKNOWN A U OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECO�IeARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. C% P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS bi 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P S 99 OTHER V, . INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. (MATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH Z SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS B EN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE ElEkT OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED B SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION R AGENCY R FACILITY ID n TANK ID a a d 1 o I Tw= 0 CURRENT LOCAL AGENCY FACILITY ID N A ROVED BY N E PHONE•WITH MEA CODE PERMIT NUMBER PERMIT AMM( OVAALL DATE PERMIT KPI ON DATE CHECCKR PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTV BY: FORMB(3-7-IB) THIS FORM MUSTBE COMPAN YAFACILITYISITEAPPUCATION, FORM 'A',UNUESS3rRRENT FORMA HASBEENFILED DATA PROCESSING COPY