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STATE OF CALIFORNIA. WATER RESOURCES CONTROL BOARD FORM B': UNDL-�jROUND STORAGE TANK PRG--AAM TANK TANK PERMIT APPLICATION INFORMATION (az COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 10 MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM F-12 INTERIM PERMIT F-14 AMENDED PERMIT El TEMPORARY TANK CLOSURE TAVNK REMOVED 9 FACILITY/SITE NAME WHERE TANK IS INSTALLED: L_. os n �'-1 l)L_ n'v FARM TANK-YES❑ NO ,A, I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY O co A. OWNERS TANK ID R U-1 5 2 o Q I B. MANUFACTURED BY: C. YEAR INSTALLED i A IA-- I D. TANK CAPACITY IN GALLONS' U V II. 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. EADEO ❑2 LEADED E] 3 DIESEL F-13 CHEMICAL PRODUCT ❑ 4 OIL 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 VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.R C.A.S.R: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,6 D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER [_1I STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 10096 METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEELUNKNOWN ❑99 OTHER C. INTERIOR F-] I RUBBER LINED ❑2 ALKYD LINING F-13 EPDXY LINING E] 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED KNOWN ❑ 15 LINING MATERIAL COMPATIBLE WITH 100%METHANOLS ❑YES ❑ NOOTHER D.CORROSION ❑ I POLYMUNE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE _,Eal9 "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 NONE A U 9 UNKNOWN AU 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 9/ NONE U UNKNOWN A U 99 OTHER A U1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE 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 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 8 1 VISUAL CHECK P 4 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P B 91 NONE P 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED IMO/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 8 SIGNATURE) - DATE LOCAL AGENCY USE ONLY COUNTY A JURISDICTION N /IAGENCY R FACILITY IDR TANK ID R EH 10 U o >> CURRENT LOCAL AGENCY FACILITY ID R APPROVED Y NAM PHONE R WITH AREA CODE Pe-TRE- ,- la PERMIT NUMBER PERMIT APPROVAL DATE PERMR EXPIRATION DATE CHECK R PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT R BY: FORM B(6-29-68) THIS FORM MUST BE ACCOMPANIED BY A FACi,SITE APPLICATION, FORM 'A',UNLESS A CURRENT ,..LM'A' MAS BEEN FlLED !IATA