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ATE OF CALIFORNIAO WATER RESOURCES CONTROL RD FORM `B': UNDERGROUNDMT APPLICATION INFORMATION TANK TANK PER COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACHTANK. `"66: " F-] 1 NEW PERMIT F--] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 10 MARK ONLY ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FARM TANK-YES❑ NO FACILITY/SITE NAME WHERE TANK IS INSTALLED: f KLG A, I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY [C. EYEAR RS TANK ID# Q B. MANUFACTURED BY: 0 INSTALLED 1 (.� D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL2 PETROLEUM B. C, [:] 1 UNLEADED ❑ 2 LEADED El3 DIESEL F-] 3 CHEMICAL PRODUCT �4 OIL ❑ 1 PRODUCT El GASAHOL ❑ 5 JET FUEL ❑ 5 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY [:] 95 UNKNOWN 2 WASTE ❑ 7 METHANOL g99 OTHER(QESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF OIL- Ill. 11 L HAZARDOUS SUBSTANCE STORED&C A.S.# CEJ L III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.&D A.TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER5 UNKNOWN SYSTEM F-] 2 SINGLE WALLED F-] 4 SECONDARY CONTAINMENT 6199 OTHER ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK F-1 5 CONCRETE El POLYVINYLCHLORIDE F] 7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE FRF MATERIAL ❑9 BRONZE F110 GALVANIZED STEEL UNKNOWN 99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR ❑5 GLASS LINING ❑ 6 UNLINED F�T%UNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYLWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑ 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 NCNE A&5 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 95 UNKNOWN A U 99 OTHER A U 1 STEELIIRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PUC) 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 A(D5 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 S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 9 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 P 5 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 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. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY fPERMIT OUNTY# JURISDICTION# AGENCY* FACILITY ID# TANK ID# I ] � � � � 1041 NT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE \ s NUM$ERPERMIT APPROVAL DATE PERMIT EX ATION DATE # PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPA D BY A FACILITY/SITE APPLICATION, FORM 'A',UNLE IZ .URRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY