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STATE OF CALIFORNIAWATER RESOURCES CONTR BOARD FORM `B': UND GROUND STORAGE TANK PR RAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. FFACILITY/SITEYNAME ARK ONL ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION' ONE ITEM ❑ 2 IN PERMIT ❑ 7 PERMANENTLY CL0_kQ T ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑fi TANK REMOVED j WHERE TANK IS INSTALLED:f d44LtA it, I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY FARM TANK-YES❑ NO A. OWNERSETAN�KlD# 5 B. MANUFACTURED BY: 21 C. YEAR INp D. TANK CAPACITY IN GALLONS: a II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. [P/' MOTCR VEHICLE FUEL ❑ 2 PETROLEUM B, C- ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL E]3 CHEMICAL PRODUCT ❑ 4 OIL �pRODUCT ❑4 GASAHOL ❑5 JET FUEL E] fi AVIATION GAS ❑ 5 HAZARDOUS ❑ BO EMPTY [:]95 UNKNOWN ❑ 2 WASTE 1:17 METHANOL E] 99 OTHER{DESCRIBE IN ITEM D,BELQWJ D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# x111. TANK CONSTRUCTION MARK ONE I EM ONLY IN BOX A,B,C,S D A. TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER SYSTEM SINGLE WALLED E]4 SECONDARY CONTAINMENT E]95 UNKNOWN �j� , ❑99 OTHER B.TANK 11 5 CONCRETE �.2 STEEL/faON ❑ 2 STAINLESSSTEEL E] 3 FIBERGLASS ❑ 4 STEEL CLAD WlffBERGLA55REINFORCED PLASTIC MATERIAL ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOLCOMPAT9LEFRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑ 2 D LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINfNG 6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ®/,,'TAR OR ASPHALT ❑3 VINYL WRAP PROTECTION ❑4 FIBERGLASS REINFORCED PLASTIC ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE &SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN p A U 1 STEEL/IRONU 99 OTHER A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C.MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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. j3ffP 1 VISUAL CHECK IPJ S 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P 5 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMAT D DATE LAST USED(MO/YR) 2. ESTIMATED O ANTPTY OF SUBSTA _ INING IN 3. WAS TANK FY LED WITH GALLONS INERT f�L? ❑ YES ❑ NQ THIS ORM HAS BEEN COMPLETED UNDER PENALTY OF P R.11IRY,AND TO THE BEST OF MY KNOWLEDGE, !S TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) - DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 00 1 1 I 6 Iv va CURRENT LOCAL AGENCY FACILITY ID# a APP VIED Y AIME PHONE#WITH AREA CODE PERMIT NUMBER D PERMIT APPROYAL A E PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT, FEE CODE RECEfPT# BY: i FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIE Y A FACILITY/SITE APPLICATION, FORMA',UNLESS A RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY