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STATE OF CALIFORN WATER RESOURCES CONTR BOARD FORM "B': UND GROUND STORAGE TANK PRI RAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING I ORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL S �NK ONE ITEM ❑2 INTERIM PERMIT ❑ q AMENDED PERMIT 8 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED C FACILITY/SITE NAME WHERE TANK IS INSTALLED: O FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# LiB. MANUFACTURED BY: C. YEAR INSTALLED , D. TANK CAPACITY IN GALLONS: )===E] II. TANK NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. KI MOTOR VEHICLE FUEL ❑ 2 PETROLEUM Bb-1 C, ❑ 1 UNLEADED ❑ 2 LEADED MD, 3 CHEMICAL PRODUCT ❑ 4 OILC m PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRI D, IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A,S.H C.A.S.M x111. TANK CONSTRUCTION MARK ONE I EM ONLY IN BOX A,B,C,b D A TYPE OF D008LE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEELIIRON ❑ B.TANK 2 STAINLESS STEEL ❑3 FIBERGLASS [:]4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC ❑ 5 CONCRETE MATERIAL ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER UNEP ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING L 6 UNLINED ❑ 95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP I� 2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A ULI 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH 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 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 095 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. ql. P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLSS 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED TE LAST USED[MO/YR) 2. EST41MAIECUANTITYOF3. WAS TANK F, LED WITH SUBAINING IN INEFIAT 1 ❑YES ❑ ND GALLONSTHIS FO HAS BEEN COMPLETED UNDER PENAL TRJURY,AND TO THE BEST OF MY KNOWLED4, 1S TRUE AND CORRECT. 1 APPLICANTS NAME(PRINTED&SIGNATURE) OATS LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID It 101r) Ejo CURRENT LOCAL AGENCY FACILITY ID p Allq PPR ED N ME PHONE tl WITH AREA CODE PER UMBER PERMIT APPROVAL PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE AMT- FEE CODE RECEIPT p BY: v FORM B(3-7-88) THIS FORM MUST BE ACCOMPA BY A FACILITY/SITE APPLICATION, FORM 'A',UNLES � RRENT FORM`A' HAS BEEN FILED DATA PROCESSING COPY