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,. STATE OF CALIFORNIO WATER RESOURCES CONTROARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM\o TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 14) MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT EGRICHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED /Jif" cAi FACILITY/SITE NAME WHERE TANK IS INSTALLED: ,S l d 4-,-9a 41 /a cp FARM TANK - YES ❑ NO W I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY, A. OWNERS TANK ID # B. MANUFACTURED BY: 6110 C. YEAR INSTALLED !. D. TANK CAPACITY IN GALLONS: l�a CD SANK CONTENT IF IA -11. IS MARKED- COMPLETE ITEM C. IF (A.11. IS NOT MARKED. COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 1 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 & 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 ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLEWALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER U 3 GRAVITY A U 91 NONE ❑ 1 STEEL/IRON 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE MINUM [:]V95 ❑ 8 100% METHANOL COMPATIBLE FAP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEELKNOWN 2 STAINLESS STEEL A ❑ 99 OTHER 4 FIBERGLASS PIPE A U 91 NONE F-]1 RUBBER LINED F-12 ALKYD LINING ❑ 3 EPDXY LINING P NOLIC LINING C. INTERIOR LINING F-]5 GLASS LINING 6 UNLINED BY: 4�95 UNKNOWN A ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT 3 L WRAP 1:14 FIBERGLASS REINFORCED PLASTIC PROTECTION [:]5 CATHODIC PROTECTION 91 NONE 495 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOV D U IF UNDERGROUND, BOTH IF APPLICABLE 3. WAS TANK FILLED WITH FACILITY ID # A. SYSTEM TYPE A U 1 SUCTION A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER CURRENT LOCAL AGENCY FACILITY ID # 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 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 6QQWQPk-ZE. A U 7 STEEL CLAD W/FRP A U 8 100% METHANOL COMPATIBLE FRP BY: A U 9 GALVANIZED STEEL 9NKN WN A 5 U U 99 OTHER �(. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. }� P S 1 VISUAL CHECK VENTORY RECONC ION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P TESTING P S 91 NONE P S 95 UNKNOWN P S 99 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 FACILITY ID # SUBSTANCE REMAINING IN INERT MATERIAL? F -]YES ❑ NO GALLONS i JK -1 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 COUNTY # JURISDICTION # AGENCY # FACILITY ID # TANK ID # [EE i JK -1 oar CURRENT LOCAL AGENCY FACILITY ID # APPROVED BY NAME PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT # BY: FORM B (6-29-88) THIS FORM MUST BE ACCOMPANIET) BY A FACILITY/SITE APPLICATION, FORM 'A', UNLESSWRENT FORM `A' HAS BEEN FILED DATA PROCESSING COPY