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STATE OF CALIFORNI ^ WATER RESOURCES CONTRC 30ARD FORM 'B': UNDERGROUND STORAGE TANK INFORMATION M Qp TANK TANK PERMIT APPLICATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. T CHANGE OF INFORMATION 7 PERMANENTLY MT MARK ONL ITTEMY ❑ 2 INTERIM PERMIT ❑4 AMENDED P PEI NEW PERMRMIT 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED CLOSED TANK N FARMTANK-YES[:] NO FACILITY/SITE NAME WHERE TANK IS INSTALLED: j I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY !, A. OWNERS TANK IDR 3 B. MANUFACTURED BY: LC T C. YEAR INSTALLED GC+ D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑4 OIL PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑BO EMPN ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF , C.A.S.W HAZARDOUS SUBSTANCE STORED&C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNR ❑95 UNKNOWN SYSTEM Ei?fSINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑810D%METHANOL COMPATIBLE ARP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN 99 OTHER ❑ 1 RUBBER LINE ❑2 ALKYD LINING ❑3 EPDXY LINING PUR PHENOLIC LINING C. INTERIOR 5 GLASS LINING ❑6 UNUNED j�j LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 LYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYLWRAP E]4 FIBERGLASS REINFORCED PLASTIC PROTECTION L,�'5 CATHODIC PROTECTION -]91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, 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 A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 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 A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U T STEEL CLAD W/FRP A U 6 /00%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 06 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. S 1 VISUAL CHECK OP S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS LI' P8 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P B 95 UNKNOWN P S 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 IV GALLONS IA /. SUBSTANCE REMAINING IN INERT MATERIAL? ❑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&SIGNANRE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY IDR TANKIDR = = Imo / 55 (o lolololl CURRENT LOCAL AOENCY FACILIiTY ID# APPROVED BY NAME PHONE#WITH AREA CODE n I PERMIPE7TAPP110VAL DA /PERMIT EXPIRATION TE \` 1 CHECK# PERMIT AMOUNT SURCHARGE MT, FEE CODE /-, R CEO(IfPT(0 BY: \~)I FORM B(6-29-86) THIS FORM MUST BE ACCOMPANI&IrA FACILITY/SITE APPLICATION, FORM 'A',UNLESS A lei ARENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY