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STATE OF CALIFORNIJA WATER RESOURCES CONTROICARD FORM 'B': UNDE ROUND STORAGE TANK PRO AM ` TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWIN2 INFORMATION FOR EACH TANK. _-- I !O MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED S FACILITY/SITE NAME WHERE TANK IS INSTALLED: _7) TANK-YES❑ NO ✓ W Q�l. `Q3) I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY W A. OWNERS TANK IDR a I B. MANUFACTURED BY: Lk K_, ��c�1 'l W C. YEAR INSTALLED LlvV'-✓ S L-41-'9 e" cJ D. TANK CAPACITY IN GALLONS: Wv "II. TANK CO TENTS 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 [-] 3 D 2 LEADED IESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL [-]6 AVIATION GAS ! ❑ 5 HAZARDOUS ❑ 80 EMPTY E] 95 UNKNOWN E]2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR HAZARDOUS SUBSTANCE STORED&C.A.S.RCLE FUEL,ENTER NAME OF C.A.S. Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,S:D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLEWA EOWITHE%IERIOR LINER ❑95 UNKNOWN SYSTEMF�J�S�INOLE WALLED,- ❑4'SECONDARY CONTAINMENT ❑99 OTHER ❑ i STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 F18EAGLSS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL �OWN ❑99 OTHER r71 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXYUNING F-]4 PHENOLIC LINING LINING ❑ C. INTERIOR 5 GLASS LINING 6 UNUNED ❑ D-9"W(NOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TARORASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONENOWN ❑ 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 AU 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 A 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 CONCRETE A U 7 STEELCLAOW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL U 5 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 8 1 VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P _t l ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 9/ NONE r�,�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 SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCVOPACILLg ID�# Lj APPROy.�D BY NA►IE PHONE#WITH AREA CODE / PERMIT NUMBER 22 PERMIT APPROVAL DATEL//(''''�PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIE B7 A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A 0ARENT FORMA HAS BEEN FILED DATA PROCESSING COPY