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STATE OF CALIFORNIA WATER RESOURCES CONTROL ARD "`• FORM 'B'-. UNDER?r.TROUND STORAGE TANK PROGRAM " TANKTANK PERMIT APPLICATION INFORMATION TANK. COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH ' ' `" 0 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ,2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED N kh(e FACILITY/SITE NAME WHERE TANK IS INSTALLED: / FARM TANK-YES❑ NO • D I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY W A. OWNERS TANK ID# B. MANUFACTURED BY: 4� C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. A. MOT OR VEHICLE FUEL ❑ 2 PETROLEUM 8. C. ❑' i UNLEADED LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL V, PRODUCT ❑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.# CA.S.N: 111. TANK CONST-RUCTION MARK ONE ITEM ONLY IN BOX A.B,C.B D A L TYPE OF i t DOUBLE WALLED ❑3%SINGLE WALLED WITH EXTERIOR UNER ❑ 95 UNKNOWN I SYSTEM SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER Ei?rmEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ 8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBERUNED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC UNING C. INTERIOR LINING ❑5 GLASS LINING F-16 UNLINED - UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYEDILENEWPAP ❑ 2 TAR OR ASPHALT ❑3 LWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLEA IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A6j 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 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE ACU UNKNOWN A U 99 OTHER A U 1 STEEUIRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM A U 6CONCRETE A U 7STEELCLADW/FRP A U 810D%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL P V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST SE CIRCLED. P 5 1 VISUAL CHECK O S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH 4M 1 SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E:]YES E] 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY K FACILITY 10# TANK ID# = = [01011 5a o00 I / CURRENT LOCAL AGENCY FACILITY ID# APPRO ED BY NAME PHONEY WITH AREA CODE PERMIT NUMBER U PERMIT APPROVALLTATh PERMIT EXPIRATION DATE OaSaP CHECK# PERMIT AMOUNT SURCHARGE AIIIAT. FEE CODE RECEIPT BY: FORM 8(6-29-88) THIS FORM MUST BE ACCOMPANIEFACILI'IY/SRE APPLICATION, FORM'A',UNLESS A L ENT FORMA' HAS BEEN FILED DATA PROCESSING COPY