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STATE OF CALIFORNI& WATER RESOURCES CONTR OARD FORM `B': UND ROUND STORAGE TANK PROM, AM TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING N4FORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT F-13 RENEWAL PERMIT ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT FACILITY/SITE NAME WHERE TANK IS INSTALLED: (r.)41;7 N - 14U 1. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY 5 CHANGE OF INFORMATION ❑ 7 PEBMANENTLY CLOSED TANK i C� 6 TEMPORARY TANK CLOSURE TANK REMOVED o 1 l FARM TANK -YESI I NO A. OWNERS TANK ID # C B. MANUFACTURED BY: V4 C. YEAR INSTALLED U K D. TANK CAPACITY IN GALLONS: goo (5-4 (-1 11. TANK "NTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, POMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED E]2 LEADED 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 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF HAZARDOUS SUBSTANCE STORED & C.A.S. # C.A.S. #: I11. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D A. TYPE OF ❑ 1 D UBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM Eff2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT 99 OTHER B. CONSTRUCTION El'i STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM 8 100%METHANOLCOMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 4 FIBERGLASS PIPE A U 91 NONE 1 RUBBER LINED 2 ALKYD LINING F-]3 EPDXY LINING HENOLIC LINING C. INTERIOR LINING F-]5 GLASS LINING F-]6 UNLINED 8 100% METHANOL COMPATIBLE FRP V95 UNKNOWN A U ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑� 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION [-]5 CATHODIC PROTECTION E]91 NONE Lam'° 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 & 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 ACU >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 W/FRP A U 8 100% METHANOL COMPATIBLE FRP RECEIPT A U 9 GALVANIZED STEEL \� 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 S 1 VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WA MONITORING WELLS PC j6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P95 UNKNOWN99 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 TANK ID # SUBSTANCE REMAINING IN INERT MATERIAL? 1:1 YES NO 1 lo lo 1It 4 S GALLONS AGENCY FACILITY ID # 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 JURISDICTION # AGENCY # FACILITY ID # TANK ID # [!El E[ I lo lo 1It 4 S 0 AGENCY FACILITY ID # APPROVED BY NAME PHONE # WITH AREA CODE � G EPERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 0 PERMIT AMOUNT --lSURCHARGE AMT. FEE CODE RECEIPT FORM B (6-29-88) THIS FORM MUST BE ACCOMPANIEDM' FACILITY/SITE APPLICATION, FORM 'A', UNLESS A CURRENT FORM `A' HAS BEEN FILED DATA PROCESSING COPY