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STATE OF CALIFORNIA WATER RESOURCESCONTRC' 90ARD FORM 'B': UND&GROUND STORAGE TANK PR61 RAM 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 PERMANENTLY CL 10 ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: , FARM TANK-YES❑ NO N W I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY (A) A. OWNERS TANK ID# (J 2. B. MANUFACTURED B - C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 2 DOO 11. TANK WNTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ETI MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED 013 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OILPRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑ 99 OTHER(DE IBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# AXd C.A.S.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF ❑1 BLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CIADWIFIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B IDA METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBERUNED ❑2 AIMUNING ❑3 EPDXY LINING ❑ 4 PHENOUC UNING C. INTERIOR LINING ❑5 GLASS LINING L21<NUNED ❑95 UNKNOWN ❑ ISLINING MATERIAL COMPATIBLE WITH 160%METHANOL? ❑YES ❑ NO 2 OTHER ✓� - D. CORROSION ❑ 1 POLYEIHLENE WRAP ❑2 TAR OR ASPHALT ❑3 LWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODICPROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMA ON CIRCLE A IFABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLEWALLED 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 STEELPRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A6 CONCRETE A U 7 STEELCLAD W/FRP A U S 100%METHANOL COMPATIBLE FAP A U 9 GALVANIZEDSTEEL 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. /),Il P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS IIIY 91 P 5 6 PRECISION TESTING P S 7 PRESSURE TESTING NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. IMATED DATE LAST USED(MONA) 2. ESTIMA DQUANTITY OF & AS TANK FILLED WITH SUB NCE REMAINING IN T MATERIAL? ❑YES ❑ NO 11 I AIA GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENAL OF PERJURY,AND TO THE BEST OF MY K OWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 4 ° 36 0O0z CURRENT LOCAL AGENCY FACILITY ID# APPXQVRD QY N PHONE#WITH AREA CODE / � /�Jyf LA'/-_ PERMIT NUMBER PERMIT APPROVAL DATE P! MR EXISIRATION DATE 1 CHECK' PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIENBY A FACILITY/SITE APPLICATION, FORM 'Al,uNLEssAWfIRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY