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STATE OF CALIFORNIS WATER RESOURCES CONTRj&OARD TANK RAM FORM `B' PR : UNDERGROUND STORAGE r ® Y TANK COMPLETE PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. I rJ MARK ONLY F-11 NEW PERMIT F-] 3 RENEWAL PERMIT 5 CHANGE OF INFORMA740N ❑7 PERMANENTLY MNONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E] 6 TEMPORARY TANK CLOSURE El8 TANK REMOVED �r7lll ; 0llll 111111111111111111111 - 1111, 111111-7711117 -L FARM TANK-YES❑ NO FACILITY/SITE NAME WHERE TANK IS INSTALLED: V l I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED I V 1D. TANK CAPACITY IN GALLONS: /�CJQ II. TANK CONTENTS IF(A•1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ BO EMPTY ❑ 95 UNKNOWN E] 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) El 5 HAZARDOUS D. 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 A.TYPE OF ❑ OUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM VINGLE WALLED ❑ 4 SECONDARY CONTAINMENT D 99 OTHER ❑ 1 STEELIIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEELOLADW/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE LUMINUM El 100%METHANOL COMPATIBLE FRP MATERIAL El9 BRONZE F-110 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑3 EPDXY LINING ❑ 4 PHENOLIC UNI NG C. INTERIOR ❑ 5 GLASS LINING ❑6 UNLINED 95 UNKNOWN LINING ❑ 1S LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO9 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT L-I LWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC ODI PROTECTION ❑ 5 CATHC PROTECTION E] 91 NONE 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 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 U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W1 FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 5 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. per// FPS 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS p]�! 6 PRECISION TESTING P S 7 PRESSURE TEST P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH I ESTIMATED DATE LAST USED(MO/YR) SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ElYES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. DATE APPLICANTS NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY FACILITY ID# TANK ID# COUNTY# JURISDICTION# AGENCY# J agLo- V VF1.8 OCAL AGENCY FACILITY iD k �+ APPROVED BY NAME PHONE k WITH AREA CODE MBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE Al:/ PERMIT AMOUNT SURCHARGE AMT. FEE CODE (/�'�y/ JBB) THIS FORM MUST BE ACCOMPANIED BY A FACILITYDATA PRI PROCESSING FO M 'A',UNLESS A CURRENT FORM'A' HAS BEEN FILED