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STATE OF CALIFORNI WATER RESOURCES CONTRI BOARD FORM B': UNDEEE-AGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK.. MARK ONLY Fq 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I O A. OWNERS TANK ID R N/lqB. MANUFACTURED BY: k C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS ' W II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. CA A. ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C0 ' ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL F-13 CHEMICAL PRODUCT IL [-] 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS VVV717 ❑5 HAZARDOUS ❑80 EMPTY ❑ 95 UNKNOWN I EP-11AS7E ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# MI.I. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEMI-YSTNGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER [❑?STEEL/IRON ❑2$]AIMLESS STEEL F-13 FIBERGLASS ❑ 4 FEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE ❑6 POLYVIWLCHLORDE F-]7 ALUMINUM ❑ 8100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN 99 OTHER ❑ C. INTERIOR 1 RUBBER LINED 1:12 ALKYD UNING F-13 EPDXY LINING E] 4 PHENOLIC LINING LINING ❑5 GLASS LINING l.UNUNED ❑ 95 UNKNOWN ❑ISUNINGMATEAIALODMPADBLEWTTHIOD%METHANOL? ❑YES ❑NO ❑ 99 OTHER D.CORROSION ❑ I POLYETHIfNE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP 4 RBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION E:4YYIQCINE ❑95 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 0 GRAVITY A U 99 OTHER B.CONSTRUCTIONA SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A 1 STEEL/IRON A U2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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 8 1VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P B PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN let S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF 3,WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INEPT MATERIAL? YES ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED B SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# z CUR ENT LOCAL AGENCY FACILITY ID APP OVE0 BY NAME PHONE#WITH AREA CODE 7(7Z #2 PERMIT NUMBER PERMTA ROVALD TE PERMIT EXPI ATION DATE CHECK 7iRMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIED&M FACILITY/SITE APPLICATION, FORM'A',UNLESS A Cbn<. NT FORMA' HAS BEEN FILED J "BATA PROCESSING COPY