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'�IP�-+^°Al�ETYI• FyR. aI^..--. -'T,v, I°,fBmw'�(i� T�1-•''i15`c.. r... STATE OF CALIFORNIAWATER RESOURCES CONTROL )ARD �'�T ff °"°:'• FORM `B': UNDERGROUND STORAGE TANK PROGRAM r� TANK TANK PERMIT APPLICATION INFORMATION ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 P MANENTLY CLOSEDT K ONE ITEM F-12 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOGURE TANK REMOVED 6 FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK -YES ❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS -IF UNKNOWN -SO SPECIFY A. OWNERS TANK ID # 8. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: d D II. TANK CONTENTS IF (A.1), IS MARKED. COMPLETE ITEM C. IF (A.11. IS NOT MARKED. COMPLETE ITEM D. A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM8. ❑ I DOUBLE WALLED C. ❑ 1 UNLEADED LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ppOpUCT ❑ 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. #: Ill. TANK CONSTRUCTION MARK ONE ItEM ONLY IN BOX A, B, C, & D A. TYPE OF ❑ I DOUBLE WALLED ❑ 3 B LE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM E]2 SINGLE WALLED ❑ 4 BE DARYCONTAINMENT ❑ 99 OTHER 1 SUCTION A ❑ I STEEUIRON ❑ 2 STAIN STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVI CHLORIDE ❑ 7 ALUMINUM ❑ 6100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ ID GALVANI STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A U 99 OTHER F -1I RUBBER UNED ID2 ALKYD LININ ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GU55 LINING ❑ fi UNLINED 3 POLYVINYL CHLORIDE (PVC) A U ❑ 95 UNKNOWN A U 91 NONE ❑ IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL. ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETH(ENE WRAP ❑ 2 TARORASPHALT❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 1:15 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, UI UNDERGROUND, BOTH IF APPLICABLE WAS TANKRLLEDWITH T/AAN,�K ID # SUBSTANCE REMAINING IN A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER CURRENT LOCALrI / CYC�LITYI N S. 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 STAINLESSSTEEL U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE Al 7 STEEL CLAD W/FRP A U 8 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SE&ONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 6 VISUAL IIECSICHECK ON TESTING P B T INVENTORY NVENTPRESSRETEST RECONCILIATION P 8 39/VNQ EE WELLS P B 4 ELECTRONIC MONITOR P S 55 GROU8 99 ND WATER MONITORING WELLS VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE UST USED(MO/YR) 2. ESTIMATED QUANTITY OFS WAS TANKRLLEDWITH T/AAN,�K ID # SUBSTANCE REMAINING IN INERTMATERIAL? ❑YES 0 14 GALLONS THIS F( RM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND C( APPLICANT'S NAME (PRINTED & SIGNATURE) DATE LOCAL AGENCY USE ONLY 3RECT. PERMIT NUMBER PERMIT APPROVAL DATE I PERMIT EKPIRATION DATE I CHECK # PERMIT AMOUNT SURCHARGE AMT. I FEE CODE I RECEIPT # BY: ORM S I6-29-891 THIS FORM MUST BE ACCOMP. !BY A FACILITY/SITE APPLICATION DATA PROCESSING COPY UNLE *UARENT FORMA' HAS BEEN FILED 10 N CO CD CD JURISDICTION # AGENCY # FACILITY ID # T/AAN,�K ID # �C"O�U�NTY /# / T colE l,/ D CURRENT LOCALrI / CYC�LITYI N APP' i ED BY IN �E �� PHONE # WRII AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE I PERMIT EKPIRATION DATE I CHECK # PERMIT AMOUNT SURCHARGE AMT. I FEE CODE I RECEIPT # BY: ORM S I6-29-891 THIS FORM MUST BE ACCOMP. !BY A FACILITY/SITE APPLICATION DATA PROCESSING COPY UNLE *UARENT FORMA' HAS BEEN FILED 10 N CO CD CD