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STATE OF CALIFORNS WATER RESOURCES CONTR OARD ` '• ND GROUND STORAGE TANK PRRAM FORM B . U .o TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT E�15 CHANGE OF INFORMATION ❑ 7 PERMANENTLYC TAN ONE ITEM ❑ 2 INTERIM PERMIT F-]4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: A-4 w� FARM TANK - YES ❑ NO I TANK nFC[_RIPTInN f`nMPI FTF Al 1 ITFIIMS _ IF UNKNOWN — SO SPECIFY A. OWNERS TANK ID # B. MANUFACTURED BY: C. YEAR INSTALLED l'g D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IC rA 11 Is MARVFn enU0I FTF ITFM C_ IF /A_11_ IS NOT MARKED. COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. 1 UNLEADED 2 LEADED 3 DIESEL ❑ 3 CHEMICAL PRODUCT OIL [:]l 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 OFW �/ HAZARDOUS SUBSTANCE STORED & C.A.S. # / OZ/` C.A.S. #: L/ III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM � 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER A U 95 UNKNOWN A U 99 OTHER STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK F-1 5 CONCRETE 6 POLYVINYLCHLORIDE F-]7 ALUMINUM F-]8 100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER 5 ALUMINUM A U 6 CONCRETE El 1 RUBBER LINED ❑ 2 KYD LINING F-13 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING 6 UNLINED U 99 OTHER ❑ 95 UNKNOWN _ ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NOEq'99'OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP 2 TARORASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN 99 OTHER IV. YIYIIY%,7 IIYrvnmm I IVIY GIHGLt A It- AbUVt UNUUNLJ, Y it Urvutn OUrvU, DWI ri lr hrr�w.+o�o 3. WAS ANK FILLED WITH A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A uA GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A_91 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 SURCHARGE AMT. 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 A U 9 GALVANIZEDSTEEL A(y 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. ZP VISUAL CHECK PIS 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMA ED DATE LAST USED (MO/YR) 2. ESTIMATED UANTITY OF 3. WAS ANK FILLED WITH TANK ID #t / 12d I SUBST AINING IN N )Ot14TERIAL? ❑ YES [:] NO A GALLONS j� THIS FORM HAS BEEN COMPLETED UNDER PENALTY Oe PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANTS NAME (PRINTED & SIGNATURE) -7 DATE 1 nt%AI At%-Cklf"V IICC nkil V COUNTY # JURISDICTION # AGENCY # FACILITY ID # IoV TANK ID #t / 12d CURRENT LOCAL AGENCY FACT ID # '3 APPROVED BY AMEX Z lYr All PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DA :RlilT EXPIRATION DATE CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE CEIPT # BY: FORM B (6-29-88) THIS FORM MUST BE ACCOMPANN?DW A FACILITY/SITE APPLICATION, FORM 'A', UNLESS A CURRENT FOR HAS BEEN FILED DATA PROCESSING COPY tcsIIIIIIIIIIIIIII DO I" fn Itz