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STATE OF CALIFORNIA WATER RESOURCES CONTRIOARD UNDE GROUND STORAGE TANK PROGRAM ;mom FORM 'B': INFORMATION TANK TANK PERMIT APPLICATION INFO ,_,_, Z COMPLETE A SEPAR79. ;5ff]p;;p LOWING INFORMATION FOR EACH TANK. 10 ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 1 NEW PERMIT rlxs>,fi REMOVED v�MARK ONLY ❑ ❑6 TEMPORARYTANK CLOSURE LiJ" ""„ I�ONE ITEM 2 INTERIM PERMITG,. f! � FARM TANK-YE8❑ NO �FACILITY/SITE NAME WNERE TANK IS INSTALL �U'TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SPECIFY CA B. MANUFACTURED BY: �- A. OWNERSTANKID# D. TANK CAPACITY IN GALLONS: - C. YEAR INSTALLED II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED COMPLETE ITEM D. ❑ 3 DIESEL B. A. 1 MOTOR VEHICLE FUEL E] B 2 PETROLEUM ❑ q GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS El3 CHEMICAL PRODUCT F-1ODUCT 4 OIL 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D. BELOW) F-15 HAZARDOUS ❑ 00 EMPTY ❑95 UNKNOWN � 2 WASTE ❑ o O. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: HAZARDOUS SUBSTANCE STORED&C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D ❑3 SINGLE WALLED WITH EXTERIOR UNER �'95UNKNOWN A.TYPE OF ❑ 1 DOUBLEWALLED ED 99 OTHER SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAIN MEM ED-5 OONC IRON 2 STAINLESS STEEL F-13 FIBERGLASS ❑4 STEEL CLAD WIFIBERGIASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑610096 METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBERLINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING C.INTERIOR ❑6 UNLINED ❑95 UNKNOWN act C� r LINING ❑ I GLASS LINING I—'1T'UT 1� ❑ IS LINING MATERIAL COMPATIBLE WITH 100%MEIHANOL? ❑YES 7 N IQ"ETHER—� D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TARORASPHALT ❑3 V'WLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION NONE ❑95 UNKNOWN ❑99 OTHER LE IV. PIPING INF ORMA ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROURNAD,VITY BOTH IF AAPUIC9 BNONE A 5 UNKNOWN A U 99 OTHER A. SYSTEM TYPE A U SUCTION A U 2 PRESSURE B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE U UNKNOWN A U 99 OTHER A U1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYLCHLORIDE(PVC) R U 81100%METHANOL COMPATIBLE FRPBERGLASS PIPE A 91 N C. MATERIAL A U 5 ALUMINUM CONCRETE A U l STEEL CLAD W/FRP A U 9 GALVANIZED STEEL U UNKNOWN A U 99 OTHER V. AK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 1VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSEWELLS P S 4 ELECTRONIC MONITOR V 8 99 OTHER W=ATER P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLED WITH 2. ESTIMATED QUANTITY OF INERT MATERIAL? []YES E] NO 1. ESTIMATED DATE LAST USED(MO/Y SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# APPROVED BY NAME �- PHONE#WITH AREA CODE CURRENT LOCAL AGEN� /`-J ACILITY IP#1 Co --,sC All PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK X PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPA BY A FACILITYPIIoN, FORM 'A''UNLESS 'URRENT FORMA' HAS BEEN FILED DATAPROCESSING