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STATE OF CALIFORNIA` WATER RESOURCES CONTRO' BOARD FORM 'B': UNDERGROUND STORAGE TANK PRO&RAM TANK �' TANK PERMIT APPLICATION INFORMATION (�IfIIAPLf}#><A*90ANAtE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS NK ONE ITEM ❑2 INTERIM PERMIT ❑ /AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/81TE NAME WHERE TANK 1$INSTALLED: _31Locke F/L/jAR TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ION B. MANUFACTURED BY: it C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: a(� II. TANK CONTENTS IF(A1),18 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM O. A. ❑ I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ I UNLEADED ❑2 LEADED ❑ 3 DIESEL F-13 CHEMICAL PRODUCT ❑ I OIL F-11 PRODUCT ❑I GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ BO 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 A C.A.S.N C.A.S.S: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,8,C.8 D A TYPE OF ❑ 1 DOUBLEWALLED ❑3 SINGLE WALLED WITH EKTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WAVED ❑A SECONDARY CONTAINMENT ❑%OTHER ❑ I STEELARON ❑2 STAINLESSSTEEL ❑3 FIBERGLASS ❑1 STEEL CUD WIFIBERGIASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑S POLYVINYLCHLORIDE ❑7 ALUMINUM ❑S 100%METHANOL COMPATIBLE FRP MATERIAL t T❑9 BRONZE ❑ 10 GALVANIZED STEEL. ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBERLINED ❑2 AUVOLINING ❑3 EPOKYLINING ❑A PHENOLICUMNG C.LIRININGIOR ❑5 GLASS LINING ❑6 UNLINED ❑%UNKNOWN ❑B LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYEIMEWWRAP ❑2 TARORAS'HALT ❑3 VINYLWRAP ❑ 1 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑%UNKNOWN ❑%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 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U O FIRERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U T STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A U 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. P ! 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P B 3 VADOSE WELLS P S 0 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 0 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 6 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE UST USED(MO/YR) 2. ESTIMATED OUANTITY 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 6 SIGNATURE) DATE t LOCAL AGENCY USE ONLY COUNTY R JURISDICTION N AGENCY N FACILITY ID N TANK ID N EE / = zo I o A CURRENT LOCAL AGENCY FACILITY IDI APPROVED BY NAME PHONE S WITH AREA CODE Lot 11 }i t3 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECKS PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTS STyT q/ / FORM B(6-29-66) THIS FORM MUST BE ACCOMPANIE 1 A FACILITY/SITE APPLICATION, FORM 'A',ULESSNA RRENT FORM W HAS BEEN FILED / DATA PROCESSING COPY