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OF CALIFORN WATER RESOURCES CONTR OARD STATE � - `SA FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION El7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑6 TEMPORARY TANKCLOSURE TANK REMOVED �q FACILITY/SITE NAME WHERE TANK IS INSTALLED: {(p { Y1 Lo ccfu�- � _I7� FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# 0 ( B. MANUFACTURED BY: a k L- C. YEAR INSTALLED x ia--� D. TANK CAPACITY IN GALLONS: I I c6c) II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICALPRODUCT ❑ 4 OIL �l PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL .OTHER(DESCRIBE IN ITEM D,BELOW) 5 HAZARDOUS ❑ 80 EMPTY D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF (��W�1 C�,��' j �� C.A.S.#: HAZARDOUS SUBSTANCE STORED&C.A.S.# A(A III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D 1 DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER .�NKNOWN A.TYPE OF ❑ ❑ SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑gg OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE 1:17 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL.,.Fa-5-U-NKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIORF-1 5 GLASS LINING ❑ 6 UNLINED _��UNKNOWN LINING [-] IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ElYES ❑ NO BOTHER ( 1 L k D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ^❑3--VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONEKNOWN ❑ 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 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 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 U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AI U�f5 UNKNOWN A U 99 OTHER PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. V. LEAK DETECTION SYSTEM CIRCLE P FOR P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE rp)s 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE F3:.WAS TANK FILLED WITH1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OFSUBSTANCE REMAINING IN NERT MATERIAL? ❑YES NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. DATE APPLICANT'S NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY FCURRENT JURISDICTION# AGENCY# FACILITY ID# TANK ID# 0 ( c ci APPROVED BY NAME PHONE#WITH AREA CODE GENCY FACILITY ID# n �LIP-y� ccL� �a PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE FEE CODE IF. IPT# BY: CHECK# PERMIT AMOUNT URCHARGE AMT. \ FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY