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STATE OF CALIFORNIr WATER RESOURCESCONTRC" '10ARD FORM 'B': UND&6ROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Go MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO,SAM ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT .❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED 1 a T9� FACILITY/SITE NAME WHERE TANK IS INSTALLED: 5 FARM TANK -YES ❑ 1 NO L I. TANK DESCRIPTION COMPLETE ALL ITEMS -IF UNKNOWN -80 SPECIFY A. OWNERS TANK IDN8. B. MANUFACTURED BY: C. YEAR INSTALLED W/ t_041�_ 1 0. TANK CAPACITY IN GALLONS: H. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. A, MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. B. UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL PRO DUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 8095 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTE AME OF HAZARDOUS SUBSTANCE STORED 8 .S. N CA.S. N: III. TANK CONSTRUCTION MAR�ONE ITEM ONLY IN BOK A, B, C, AD A TYPE OF ❑ 1 DOUBLE WALLED 3 SNGLE WALLED NTH EXTERIOR UNER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED 4 SECONDARY CONTAINMENT ❑ 99 OTHER A ❑ 1 STEELPRON ❑ STAINLESSSTEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 YVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8100% METHANOL DOMPATIBLEFRP U 3 LINED TRENCH A U 91 NONE ❑ 9 BRONZE ❑ 10 VANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A ❑ 1 RUBBER LINED ❑ 2 ALKYD MING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC UNING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNUNED C. MATERIAL ❑ 95 UNKNOWN U 5 ALUMINUM A ❑ IS UNING MATERIAL COMPATIBLE WITH 1OD%METH L? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHAL ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUN U IF UNDERGROUND, BOTH IF APPLICABLE 2. ESTIMATED OUANTITA OF3. WAS TANK FILLED WITH I �COUNTY � = A. SYSTEM TYPE A U i SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER VP— B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WA ff A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U i STEEL/IRON A U 2 STAINLESS S EL A U 3 POLYVINYLCHLORIDE(PVC) A U 4 FISERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U S 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 SVOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P B 3 VAD E WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S I PRECIS ION TESTING P S 7 PRESSURE TESTING P 8 91 NON P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED I)N PLACE 1. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED OUANTITA OF3. WAS TANK FILLED WITH I �COUNTY � = SUBSTANCE REMAINI IN INERT MATERIAL? ❑ YES❑ NO CURRENT LOCAL AGENCY FACAITY ID N GALLONS APPROVED BY NAME THIS F( LOCAL AI RM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, ND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND C( APPLICANT'S NAME (PRINTED 8 SIGNATURE) PATE :FNlry usF nNll v RRECT. N JURISDICTION N AGENCY N FACILITY ID# TANK ID N I �COUNTY � = = 0011= CURRENT LOCAL AGENCY FACAITY ID N APPROVED BY NAME PHONE N WITH AREA CODE VP— PERMIT NUMBER PERMITAPPROVAL DATE PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT I SURCHARGE AMT. I FEE CODE I RECEIPTN BY: � f 'ORM B (6-29-881 THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION. FORM 'A'. UNLESS A'r IRRFNT FORMA' NAS RFFN FII FO DATA PROCESSING COPY