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STATE OF CALIFORNI/ WATER RESOURCES CONTROP *)ARD FORM 'B': LINDEOROLIND STORAGE TANK PROMAM TANK TANK PERMIT APPLICATION INFORMATION m COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - ^� 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENT VCLO K ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ANK REMO D OIF p ^ w FACILITY/SITE NAME WHERE TANK IS INSTALLED: s U k SSon/ TANK-YES NO w I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY W A. OWNERS TANK ID# '-7 V B. MANUFACTURED BY: I"A C. YEARINSTALLED D. TANK CAPACITY IN GALLONS: 17- 0 11. TANK CONTENTS 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 F-13 CHEMICAL PRODUCT �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 HAZARDOUS SUBSTANCE STORED&C.A.S.#CLE FUEL,ENTER NAME OF Y-'C.A.S.#: 68y7VI30A III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,&D A. TYPE OF ❑ DOUBLE WALLED F-13 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM SINGLEWAU-ED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE E]6 POLYVINYL CHLORIDE ❑ UMINUM ❑8100%METHANOL COMPATIBLEFRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL Lo 95 UNKNOWN ❑99 OTHER C.INTERIOR F-11 RUBBER LINED ❑2 ALKYD UNING ❑3 EPDXY LINING n%PfIENOUCUNING LINING ❑5 GLASS LINING ❑ X19 6 UNLINED 95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH im mE HANOLP ❑YES/ ❑NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TARORASPHALT n 35IINYL WRAP ❑4 FIBERGLASS REINFORCED PLABRC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE Ir(y�-L/95 UNKNOWN ❑99 OTHER IV. PIPING INFOR MAT ON 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 A U 5 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 -ACA U 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A 7 S7EELCLAD W/FRP A U 810METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN U 99 OTHER 0% V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. N""'��'�1 ktX 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS 1- P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE 4v 8 95 UNKNOWN P 8 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 SUBSTANCE REMAINING IN GALLONS 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 B SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 9 = = lolollYYWIriUo .-Y CURRENT LOCAL AGENCY FACILITY IDN APPROVED BYNAME PHONE x WITH AREA CODE F(/EG Z-z/-:F� L✓-_1 PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-69) THIS FORM MUST BE ACCOMPANI D BY A FACILITY/SITE APPLICATION, FORM 'A',UNLEAWFOURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY