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STATE OF CALIFORNlib WATER RESOURCES CONTROMOARD Go FORM 'B': UNDE GROUND STORAGE TANK PROGRAMTANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK o ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED `J' FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO (JI I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY ~ A. OWNERS CD TANK ID# B. MANUFACTURED BY: la C. YEAR INSTALLED U 0. TANK CAPACITY IN GALLONS: Q II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A ❑ 1 MOTOR VEHICLE FUEL ❑ 2.PETROLEUM e. G ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT �4 OIL ❑ 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN 6CJ 2 WASTE ❑ 7 METHANOL OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF /J HAZARDOUS SUBSTANCE STORED&C.A.S.# Z"- C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑�1 DOUBLE WALLEO ❑3 SINGLE WALLED WITH EXTERIOR UNER L]95 UNKNOWN SYSTEM ®2 SINGLE WAILED ❑4 SECONDARY CONTAINMENT ❑W OTHER En i STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ MATERIAL 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBERLINED ❑2 C. INTERIOR A D ❑ 3 EPDXY LINING 4 PHENOLIC LINING LINING ❑ LINING 0 5 GLASSLINING goaf UNLINED 95❑YES ❑ NO �OTHERS L& "'� IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? D. CORROSION ❑ i POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FlBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IFUNDE UND,BOTH IF APPLICABLE A. SYSTEM TYPE A U LOTION A U 2 PRESSURE A kU GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEELPRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE 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 5 UNKNOWN A U 99 OTHER V. LEAK DETECTIONS STEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. �yy�pd"P CH $ 21NVENTORY.RECONCILIATION 3VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS PVA! B 7 PRESSURE TESTING S 1 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE rST USED(MO/YR) 2. ESTIMATED D ANTITY OF 3.W STANK FILLED WITH SUBSTANCE INING IN MATERIAL? ❑YES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF P RJURY,AND TO THE BEST OF MY KNO LEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION# AGENCY# FACILITY ID# TANK ID# 3 �!LFACILITYCURRENT LOkAAP p DBYN ME PHONE#WITH AREA CODE PERMMIIT{NNUMBERPERMIT APPROVAL DATE //'/L PE//RMIT EXPIRATION DATE CHECK# SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED br A FACILITY/SITE APPLICATION, FORM 'A',UNLESS AC .ENT FORMA' HAS BEEN FILED DATA PROCESSING COPY