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STATE OF CALIFORPW WATER RESOURCES CONTISBOARD ,.. FORM'B': UND RGROUND STORAGE TANK PR GRAM TANK TANK PERMIT APPLICATION INFORMATION® ° COMPLETE A SEPARATE FORM WITH THE FOLLOWIN FORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION❑ 7 RE NENTLY CLO D TAM ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E]6 TEMPORARY TANK CLOSURE TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK -YES ❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOV#N _ c0 cevrmv A. OWNERS TANK ID # B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 1 Q U d A. L ' MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B C. 1 UNLEADED ❑ 2 LEADED E:]3 DIESEL F-13 CHEMICAL PRODUCT 4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS 05 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN E]2 WASTE ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAMEF HAZARDOUS SUBSTANCE STORED 8 C.A.S. #C.A.S. If TANK CONSTRUCTION MARK ONE IMM nM1 V IM nnv . e n — A. TYPE OF ❑ I DOUBLE WALLED ❑ 3 BIN EWALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑ 4 SECO ARY CONTAINMENT ❑ gg OTHER B. ❑ 1 STEEL/IRON ❑ 2 STAINLES TEEL 3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYLC LORIDE ❑ 7 ALUMINUM ❑ 8100% METHANOL COMPATIBLE FRP A ❑ 9 BRONZE ❑ 10 GALVANIZED EEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑1 RUBBER LINED ❑2ALKYD LINING ❑ 3EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT 3 VIN'YLWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED U 3 POLYVINYL CHLORIDE (PVC) A U A U 1 STEEL/IRON A U 2 STAINLESS STEEL 7STEEL CLAD W/FRP A U C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 9 GALVANIZED STEEL A U 95 UNKNOWN JDERGROUND, BOTH IF APPLICABLE 7U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE A U 91 NONE A U 7STEEL CLAD W/FRP A U 8100% METHANOL COMPATIBLE FRP A 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR S ONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSEWELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLA E 1. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑ YES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TOT E 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 # q D CS I all CURRENT LOCAL AGENCY FACILITY ID M. APPROVED BY NA E PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PER IT EXPIRATION DATE CHECKM PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTM BY; FORM B (6-29-88) THIS FORM MUST BE ACCOMPANIE A F CILITY/SITE APPLICATION, FORM `A', UNLESS A RE FORMA' HAS BEEN FILED DATA PROCESSING COPY z 10 N CJ1 CO W IN,