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STATE OF CALIFORNI WATER RESOURCES CONTRr- BOARD GO FORM4B': UNDrfiGROUND STORAGE TANK PRMRAM TANK PERMIT APPLICATION INFORMATION Z TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ,0 MARK ONLY ❑ I NEW ;PAR 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 7 P RMANENTLY CLOSED TANK ONE ITEM 2 INTERMIT El 4 AMENDED PERMIT 0 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED _� FARM TANK-YES❑ NO FACILITY/SITE NAME WHERE TANSTALLED: O 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECT N FA. OWNERS TANK ID# ".Z 2 V 1 B. MANUFACTURED BY: k A OWNERS TAENKIDND. TANK CAPACITY IN GALLONS: 3 C. YEAR INSTALLED 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. YPRODUCT C. 1 UNLEADED E] 2 LEADED 3 DIESEL A. -MOTOR VEHICLE FUEL 0 2 PETROLEUM 4 GASAHOL E]5 JET FUEL 6 AVIATION GAS 3 CHEMICAL PRODUCT 4 OIL 5 HAZARDOUS BO EMPTY 95 UNKNOWNTE El 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF CAS.W HAZARDOUS SUBSTANCE STORED 8 C.AS,# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,8,C,8 D ❑ 1 DOUBLEWALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN A TYPE OF SYSTEM 59 SINGLEWALLED 4 SECONDARY CONTAINMENT 99 OTHER -E .S EEUIRON F-1 2 STAINLESS STEEL O 3 FIBERGLASS 4 STEEL CLAD WIFIBERGLAS9 REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE El 7 ALUMINUM B IDAMETHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE F-1 10 GALVANIZED STEEL El 95 UNKNOWN F-1 99 OTHER I RUBBER LINED2 ALKYD LINING F-13 EPDXY LINING [:] 4 PHENOLIC LINING C. INTERIOR 5 GLASS LINING —+6 UNUNED F-195 UNKNOWN LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES E] NO F-1 99 OTHER D.CORROSION ❑ I POLYETHUENEWRAP TAR OR ASPHALT 3 VINYL WRAP F] 4 FIBERGLASS REINFORCED PLASTIC PROTECTION F-1 5 CATHODIC PROTECTION [:]91 NONE 95 UNKNOWN El 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 91 NONE A U 95 UN N 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 5 UNKNOWN'5 A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCR A U 7 STEELCLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 5 KNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S i VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS e S 4 ELECT NITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE C-vS UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED IMO/YR) 2. ESTIMATED QUANTITY OF 3,WAS TANK FILLED WITH r- SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? YES 0 NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# M = O CURRENT LOCAL AGENCY FACILITY ID j APPRQVEDBY ME' I ` � `� PHONE#WITH AREA CODE \ PERMIT NUMB is PERMIT APPROVAL DATEEE PERMIT EXPIRATION DATE CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT• BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPAN&O A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A ENT FORMA' HAS BEEN FILED _ DATA PROCESSING COPY