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STATE OF CALIFORNIS WATER RESOURCES CONTROBOARD FORM B': UNDERGROUND S L RAGE ANFO MOTION TANK TANK PERMIT APP z COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. I O MARK ONLY 1 NEW PERMIT F-] 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLYCLOS ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED Q Ca ARM TANK-YES❑ NO W FACILITY/SITE NAME WHERE TANK IS INSTALLED: M S (� I. MYEAR CRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY B. MANUFACTURED BY: ANK ID# ALLED p D. TANK CAPACITY INGOLLONS: p'O II. TANK CONTENTS IF(A.1),IS Mq ED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. G C. ❑ 1 UNLEADED ❑ 2 LEADED 3 rES A. 1 MOTOR VEHICLE FUEL ❑ 2 PET !/ ❑ �1 PRODUCT ❑4 GASOHOL ❑ 5 JF1f9EgqL�, N GAS 3 CHEMICAL PRODUCT 4 OIL 7 METHANOL 99 OTHER( RI ELOW) ❑ 5 HAZARDOUS ❑ BO EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ ❑ D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: � I HAZARDOUS SUBSTANCE STORED 8,C.A.S.# ry III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX a,B,C,A D ,i 7w`1 A.TYPE OF I DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINME T ❑99 OTHER 1 STEELIIRON ❑2 STAINLESS EL 3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLABTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE. ❑?ALUMINUM ❑B IW%METHANOL COMPATIBLE FRP MATERIAL ❑y BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING E]4 PHENOLIC LINING C.INTERIOR ❑5 GLASS LINING ❑6 UNLINED 95 LINING UNKNOWN F-1ISLINING MATERIAL COMPATIBLE WITH 100%METHANOL? DYES ❑ NO OTHFA D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TARORASPHALT ❑3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE u95 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 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 A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4100%METHAN FIBERGLASS L A U LE NONE C. MATERIAL A U 5ALUMINUM AJL 6CONCRETE A U 7STEEL CLAD W/FRP A U 8100%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 S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. �L S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS 7 P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 9 95 UNKNOWN P 8 99 OTHEfl VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLED WITH 1. ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF INERT MATERIAL? ❑YES ❑ NO SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOW TE DGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY FNUMBER SDICTION# AGENCY# FACILITY ID# TANK ID# / APPROVED BY NAME PHONE#WITH AREA CODE LITY ID# SL PERMIT APPROVAL(DyA(TyE PERMIT E%PIRATION DATE Z Z d O BY: CHECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE ECEIPT# FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED / 0A,TA PR0C.;ESS!N1t' r ..