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STATE OF CALIFORN# Y"' LER RESOURCESOC NTROARD 4 FORM `B': UND*RGROt NK 3 STORAGE TAPR RAM TANK TANK PERMItIPPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - G 10 MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑7 RMANENTLY CrEiR o ,o.NK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT S TEMPORARY TANK CLOSURE 6 TANK REMOVE cn FACILITY/SITE NAME WHERE TANK IS INSTALLED: 6 FARM TANK-YES NO ❑ N 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY CJJ t0 A. OWNERS TANK ID# 0 B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: DO II. TANK ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A7),IS NOT MARKED,COMPLETE ITEM D. A. Effl MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL RODUCT [—] 4 GASAHOL 5 JET FUEL [:] 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑ 1 P2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARKONE ITEM ONLY IN BOXA,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 1 STEBUIRON 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM B 199%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 16 GALVANIZED STEEL [::]95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑2 LINING ❑ 3 EPDXY LINING F-1 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING 6 UNUNED ❑95 NOWN� -- [_] IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO %OTHER `UA- — / D. CORROSION ❑ 1 POLYEIHLENE WRAP 1012 OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMA ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE - SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER S. CONSTRUCTION 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 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A ^6 CONCRETE A U 7 STEELCLADW/FRP A U 910096 METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A cy 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. 0 p1G P S 1VISUAL CHECK P 5 2INVENTORY RECONCILIATION 3VADOSE WELLS P S 4ELECTRONIC MONITOR P 8 SGROUND WATER MONITORING WELLS P 5 6 PRECISION TESTING P S 7 PRESSURETESTING (P / NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTL CLOSED IN PLACE 1. ESTIM TED DATE LAST USED(MO/YR) 2. ESTIM TEDDFINTY OF 3, WA TANK FILLED WITH P S 8 AJ�CE REMAININGN MATERIAL? ❑YES ❑ NO rl GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRE T LOCAL AGENCY FACILITY ID# APPF19VED BY NAM PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRA ION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: _ FORMB(6-29-88) THIS FORM MUST BE ACCOMPANIE FACILRY/SITE APPLICATION, FORM`A',UNLESSA ENT FORNI HASBEENRLED �'y%: DATA PROCESSING COPY