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Y1pr'r..F • --rr.^g- . STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM ;mom TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. — - 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK (� MARK ONLY ❑ ❑ ❑ ❑ ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ffrs TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY CA) A. OWNERS TANK ID# B. MANUFACTURED BY: toAlk- C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑1 MOTOR�LEHICLE FUEL ❑ 2 PETROLEUM B. C. E' 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL ❑55 FUEL ❑6 AVIATION GAS 5 HAZARDOUS ❑60 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑7 METHANOL �i OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF � " '�� -� /j� 7 HAZARDOUS SUBSTANCE STORED&C.A.S.# s K-4 tA5Ljo�tkw-p C.A.S.w III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D I BLE WALLED F--13 SINGLE WALLED WITH DnRIOR LINER ❑95 UNKNOWN A TYPE OF ❑ SYSTEM J..11 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER STEEUIRON ❑2 STAINLESS STEEL F-13 FIBERGLASS E]4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE E]S POLYVINYLCHLORIDE F-17 ALUMINUM ❑6100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ 1 RUBBER UNEO ❑2 DLINING ❑ 3 EPDXY LINING ❑4 PHENOLIC UNING LINING ❑ 5 GLASS LINING 6 UNLINED ❑95 [:]ISUNING MATERIAL COMPATIBLE WITH 100%MEN(ANOL? ❑YES ❑NO 99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TARORASPHALT ❑ INYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ S CATHODIC PROTECTION ❑91 NONE Z 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 UNEDTRENCH A U 91 NONE A U>5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A(utolNONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U S 10096 METHANOL COM LE FRP A U 9 GALVANIZEDSTEEL A U 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. �` -P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS PP S 6 PRECISION TESTING P S 7 PRESSURE TESTING P i NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMAjqb DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS K FILLED WITH CE REMAINING IN TERIAL? ❑YES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALfi OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRIMEDBSIGNATURE) GATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# GU I / DD lo CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NA PHONE#WITH AREA CODE 5 n -z0 Z PERMIT NUMBER PERMIT APPROVAL DATE I PEftMIT EXPIRATION WITS CHECKN PERMIT AMOUNT URCHARGE AMT. FEE CODE RECEIPT N BY: FORMB(6-29-66) THIS FORM MUST BE ACCOMPANIED WAFACIUTY/SITE APPLICATION, FORM 'N,UNLESS AC RENT FORMA' HASBEENFILED DATA PROCESSING COPY