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STATE OF CALIFORNI WATER RESOURCES CONTRC 1OARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM =mom TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWIN5,INFORMATION FOR EACH TANK. - 7v, !O MARK ONLY ❑ 1 EW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION El PERMANENTLY CLOSED NK ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED I 0 N FACILITY/SITE NAME WHERE TANK IS INSTALLED: 1 FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SOSPECIFY o A. OWNERS TANK ID# B. MANUFACTURED BY: 00 C. YEAR INSTALLED U D. TANK CAPACITY IN GALLONS. ESQ II. TANK CdNTENTS IF(A.1),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 2 LEADED ❑3 DIESEL 'I ❑ 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 ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.N III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ I BE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM INGLE WALLED ❑4 SEDONDARYCONTAINMENT ❑ 99 OTHER 1 STEEUIRON ❑2 STAINLESS STEEL F-13 FIBERGLASS F74 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑6100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑W OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD UNING ❑ 3 EPDXY UNING �ENOUC LINING C.INTERIOR p ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN V iiK ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑2 TARORASPHALT ❑ WNYLVIRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IFUNDERGROUND,BOTH IFAPPLICABLE A.SYSTEM TYPE A j'Uj 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH A U 91 NONE 95 UNKNOWN A U 09 OTHER A U1 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 {L 6 CONCRETE A U 7 STEELCLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A [C/7 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. liS I VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS pp): 6 PRECISION TESTING P 8 7 PRESSURE TESTING I P 8 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. NFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED IMO/YR) 2. ESTIMATED QUANTITY OFGALLONS 3.WAS TANK FILLED WITH 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 A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# Lal 161-0 11FTYM 101010 CURRENT LOCAL AGENCY FA LI Ip IL i� / ' / APPROVED BY NAME PHONE WITH AREA CODE T�7y N v Z_-1("57/(BY� PERMIT NUMBER PERMIT APPRO AL DA PERMIT EXPIRATION DATE CHECK* PERMITAMOUNT I SURCHARGE AMT. FEE CODE RECEIPT* BY: S FORM B(6-29-99) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A CURRENT FORMA' HAS BEEN FILED /