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STATE OF CALIFORN WATER RESOURCES CONTRQJIOARD F~ FORM `B': UND GIROUND STORAGE TANK PR RAM TANK TANK PERMIT APPLICATION INFORMATION Y� COMPLETE A SEPARATE FORM WITH THE FOLLOWING,INFORMATION FOR EACH TANK. Y� MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C K ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: b FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY I A. OWNERS TANK ID# D B. MANUFACTURED BY: C. YEAR INSTALLEDtq D. TANK CAPACITY IN GALLONS: !004 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. G. [:] 1 UNLEADED ❑ 2 LEADED DIESEL 1 K3 CHEMICAL PRODUCT ❑ 4 OIL '00 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL [:] fi AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# Aj 1,4 C.A.S.#: x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C.&D A. TYPE OF ❑ I DOUBLE WALLEO ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM L r l `SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑V 11 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS E] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B,TANK 5 CONCRETE MATERIAL ❑ ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER ❑ C. INTERIOR 1 RUBBERLINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING E] 4 PHENOLIC LINING LINING ❑5 GLASS LINING P16 UNLINED ❑95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ®95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMA ION 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 99 OTHER B.CONSTRUCTION A U 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 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 8 100%METHANOL COMPATIBLE FRP A U 9 GALVAN12EDSTEEL A lu 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. G P 1 VISUAL CHECK p S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELLS �f 6 PRECISION TES7ING 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. E TI ATED DgTE LAST USED(MO/YRX 2. ESTI A- D QUANTITY OF 3. WAS TA - FILLED WPTH S REMAINING RN fNE T A E IAL7 ❑YES ❑ NO GALLONS THIS FORM NAS BEEN COMPLE71 D UNL?ER PENALTY OF PERJUFY,AND TO THE BEST OF MY KNO WLED E, !S TRUE ANa CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# EE I 1 1:1 L I I I o I [ �, I Iol In, T-o7l CURRENT LOCAL AGENCY FACILITY ID# P OVED Y NAME PHONE#WITH AREA CODE ��' 6 In UK PER NUMSE PERMIT APPROVAL D TE PERMIT EXPIRATION DATE •� CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY, U FORM B(3-7-8a) THIS FORM MUST BE ACCOMPANI Y A FACILITY/SITE APPLICATION, FORM `A',UNLESS A WRRENT FORM`A' HAS BEEN FILED DATA PROCESSING COPY