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_ 1 TATE OF CALIFORNI WATER RESOURCES CONTR OARD FORM 'B': UNDMbROUND STORAGE TANK P TANK AM TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 1 NEW PERMITF];13;AMEN;DED ERMIT �CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK MARK ONLY ❑ ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED 5 ONE ITEM F-12 INTERIM PERMIT PERMIT FARMTANK-YES❑ NO z FACILITY/SITE NAME WHERE TANK IS INSTALLED: r I G 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY iJ B. MANUFACTURED BY: 1." A. OWNERS TANK ID# w�` D. TANK CAPACITY IN GALLONS: (A) C.YEAR INSTALLED YA. IV 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. Q B C. UNLEADED ❑ 2 LEADED ❑ 3 DIESEL (� A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM ❑ ❑ PRODUCT ❑<GASAHOL E] 5 JET FUEL ❑6 AVIATION GAS 3 CHEMICAL PRODUCT 4 OIL ❑ ❑ ❑ ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) 5 HAZARDOUS BO EMPTY ❑95 UNKNOWN 2 WASTE D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: HAZARDOUS SUBSTANCE STORED&C.A.S.# KIEI. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,S D 1 DOUBLEWALLEO ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN A TYPE OF F-1 SYSTEM ❑2 SINGIEWALLE99 OTHER O ❑4 SECONDARY CONTAINMENT ❑ 1 STEELIIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED57EB. ❑95 UNKNOWN ❑99 OTHER ❑ I RUBBER LINED ❑2 ALKYD UNING ❑3 EPDXY UNING ❑4 PHENOLIC LINING C. INTERIOR ❑5 GLASSUNING ❑6 UNUNED E94 UNKNOWN LINING ❑IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 99 OTHER D. CORROSION ❑ 1 PMYETHLENE WRAP ❑2TAR OR ASPHALT ❑ 3VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATRODICPROTECTION ❑91 NONE ©.9S 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 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH A 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE IPVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U S ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8109%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A O 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 1VISUAL CHECKOP S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS �YTX• p S 9i NONE-6 PRECISION TESTING P S 7 PRESSURETESTING P P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE ESTIMATED QUANTITY OF 3.WAS TANK 61LLED WITH 1. ESTIMATED DATE LAST USED(MO/YR) 2. SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES E] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. DATE APPLICANTS NAME(PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# cOQ � a 7 1 6D0 APPROVED BY NAME 40 PHONE N WITH AREA CODE CURRENT LOCAL AGENCY FACILITY ID# //%�' PERMIT NUMBER PER MITAPPROVALDATE RMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE CEIPT# BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIED Y A FACILITY/SITE APPLICATION, FORM `A',UNLESS A CURRENT FORMA HAS BEEN FILED A PROCESSING CC: