SITE INFORMATION AND CORRESPONDENCE

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ST ,T,E OF CALIFORNIA WATER RESOURCES CQNTRO ARD FORM-'B': UNDERGROUND STORAGE TANK PROAM y � a TANK TANK PERMIT APPLICATION INFORMATION !� { COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. a^ MARK ONLY ❑ 1 NEW PERMIT F-1 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: l&ARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN---SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: PETE(0C� I r(J" C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: r II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS`NOT MARKED,COMPLETE ITEM D. A. ED04MOTOR VEHICLE FUEL F-] 2 PETROLEUM B. C. ❑ 1 UNLEADED LEADED F-] 3 DIESEL 3 CHEMICAL PRODUCT 4 OIL PRODUCT ❑4 GASAHOL 5 JET FUEL 6 AVIATION GAS 'E]5 HAZARDOUS 80 EMPTY [:] 95 UNKNOWN 2 WASTE O 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S_#: III: TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A:TYPE OF ❑ 1 DOUBLE WALLED F-1 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEMSINGLEWALLED ❑4 SECONDARY CONTAINMENT E]99 OTHER EELIIRON 2 STAINLESS STEEL � 3 FIBERGLASS 4 STEEL CLAD WIFIBERGLASS REINFORCED PIAST}C B.TANK P5 CONCRETE Ej 6 POLYVINYLCHLORIDE F 7 ALUMINUM 6 f00%METHANOLCOMPATIBLE FRP MATERIAL 9 BRONZE- 10 GALVANIZED STEEL [::] 95 UNKNOWN 99 OTHER F] 1 RUBBER LINED 2 ALKYD NG F-13 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR LINING - 5 GLASS LINING LINED 95 UNKNOWN �r IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES . .❑.NO F�j99 OTHER r N 1/� Tom✓ D.CORROSION ❑ 1 POLYETHLENE WRAP F-�2 TAR OR ASPHALT F-1 3 VINYL WRAP E]4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION �1 NONE 95 UNKNOWN 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,'BOTH IF APPLICABLE. A.SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91-NONE A U 95 UNKNOWN A U 99 OTHER ra B.CONSTRUCTION A V 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE U 95 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 WIFRP A V 8 100%METHANOL COMPATIBLE FRP A U. 9 GALVANIZED STEEL A UNKNOWN A U 99 OTHER I' V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER I. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YRy 2. ESTIMATED QUANTITY OF3. WAS TANK FILLED WITH - SUBSTANCE REMAINING IN , INERT MATERIAL? E]YES ED] NO _ GALLONS THIS FORM HAS SEE COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. , M, APPLICANT'S NAME{PRINTED&SIGNATURE) .DATE LOCAL AGENCY USE ONLY r(6-29-88), JURISDICTION# AGENCY# FACILITY ID# TANK ID# ' AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE j MfAF � PERMIT APPROVAL DATE P RMS PI TION ATE - PERMIT AMOUNT SURCHARGE AMT. FEE CODE / RECEIPT# 7�- CHECK FORM 'A' UNLESS A ENT FORMA' HAS BEEN FILED !} HIS FORM MUST-BE ACCOMPANY A FACILITY/SITE APPLICATION, , " LOCAL AGENpY COPY !4.