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STATS OF CALIFORNO WATER RESOURCES CONTgOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION u = , COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK FFACILITY/SITE RK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ELK NE ITEM CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO K ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED NAME WHERE TANK IS INSTALLED: e FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# C� B. MANUFACTURED BY: -�' C. YEAR INSTALLED C' D. TANK TY IN If.rA. 1 TENTS IF(A.T�,IS MARKED,COMPLETE ITEM C.IF(A:),IS NOT MARKT D,COMPETE IT Q R VEHICLE FUEL ❑ 2 PETROLEUM EM D, B' C. ❑ 1 UNLEADED ❑2 LEADEQCAL PRODUCT ❑4 OIL � �3 DIESEL L _I PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS DOUS ❑ EMPTY ❑ 95 UNKNOWNR VEHICLE FUEL,ENTER NAME OF 2 WASTE7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) SUBSTANCE STORED&CA S,# L1 III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BO/XGA,B,C,&D C.A.S.#: A. TYPE OF 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER SYSTEM ❑2 SINGLE WALLED 0 ❑95 UNKNOWN SECONDARY CONTAINMENT ❑99 OTHER J�JMATERIAL El 5 CONCRETE I STEEL/IRON ❑2 STAINLESS STEEL B.TANK ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC ❑9 BRONZE ❑6 POLYVINYL CHLDRIDE 7 ALUMINUM ❑B 1OD%METHANOL COMPATIBLE FRP ❑ 10 GALVANIZED STEEL 0 95 UNKNOWN El 99 OTHER C. INTERIOR � 1 RUBBER LINED ❑2 ALKYD LINING LINING ❑5 GLASS LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑ YES ❑ NO Rj 99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TARORASPHALT PROTECTION ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC r 5 CATHODIC PROTECTION ❑91 NONE ❑95 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 B. CONSTRUCTION A U 1 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 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 9 GALVANIZED STEEL A A U 99&/95 UNKNOWN OTHER A U 8 100%METHANOL COMPATIBLE FRP V. LEAK DETECTION 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 P S 3 VADOSE WELL P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VL. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATE DATE LAST USED(MO/YR) 2. ESTIMATED UANTITY pF SUBST NG MAINlNG IN 3 WRS T K FILLED WITH GALLONS IN RT A ERIAL? ❑ YES ❑ NO THIS ORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWL DGE,!S TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID TAMC ID# aE�IzjRB T LOCAL AGENC FACILITY f0# d 17 J' j APPROVED, NAM PHONE#WITH AREA CODE PERMITNUMBER k g— 6d PERMIT APPROVAL DATE P RM EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT, FEE CODE RECEIPT# BY: FORM B(6-P9-B8) THIS FORM MUST BE ACCOMPANIEUr A FACILITY/SITE APPLICATION, FORM `A',UNLESS A :RENT FORM`A° DATA PROCESSING COPY HAS BEEN FILED