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STATE OF CALIFORN& K PROGWATER RESOURCES CONTP BOARD FORM `B': UND RGROUND STORAGE TAIRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY //''��❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION PERMANENTLY CLOSED TANK ONE ITEM C��❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REM FACILITY/SITE NAME WHERE TANK IS INSTALLED: a(J'5- M ARM TANK-YES❑ NO I. TANK DESCRIPTIONCOMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY p A. OWNERS TANK IDti B. MANUFACTURED BY' b U r C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: I. TANK COMTEWTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,CO Pfl ITEM D. FV A. 7 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. p 0. LEADED 10 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT / 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ (i0 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.# v/� CAS KIII. TANK CONSTRUCTION MARKONE ITEM ONLY IN BOX A ,C,&D A TYPE OF ❑ I DOUBLEWAUfD ❑3 SINGLE WALLED WITH EXTERIOR LINEfl5 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/RBERGLASS REINFORCED RASRC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑7 ALU ❑B 100%METHANOL COMPATIBLE FAP MATERIAL ❑9 URONZE 10 GALVANIZEDSIEEL UNKNOWN ❑99 OTHER ❑ I RUBBERUNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHEN INING G LINING RO❑ ❑ LINING 5 GLASS LINING 8 UNUNEO r1 NKNOWN ❑ IS LINING MATERIAL COMPATIBLEW101100%METHANOL. ❑YES r� NO ❑99 OTHER D.CORROSIO I� I POLYETHLENEWRAP ❑2TAR OR ASPHALT ❑3 VINY AP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION 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.CONSTRUCTIO A U i 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 FIBERGLASSPIPE C.MATERIAL A U S ALUMINUM A U 6 CONCRETE A U 7 STEELCLAOW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A M5 UNKNOWN A U 99 OTHER . L ETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION PS 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING ADS 91 NONE- P S 95 UNKNOWN P S 99 OTHER 1� VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE MATED DATE LAST USED MO/YR) 2. ESTIMATED OUANTITY OF 3. WAS TANK FILLED WITH -/17// SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS B EN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LO,QAL AGENCY USE ONLY OUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 3 �� o / CU T LOCAL A /ENNCCY�FACILITY ID q �A V BYNAME PHONE#WITH AREA CODE 4106A �47�V1J� IT NUMBER TAPPROVA TE P NIT PIRATIOND CHECK# PERMIT AMOUNT SURCH GE AMT. FEE CODE RECEIPT# BY: FORM B(3-7-BB) THIS FORM MUST BE ACCOMPANW A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A WRENT FORMA HAS BEEN FILED DATA PROCESSING