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- STATE OF CALIFORNI& WATER RESOURCESCONTR�OARD FORM B': UND ROUND STORAGE TANK PR AM "J TANK TANK PERMIT APPLICATION INFORMATION � r COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 RMANENTLY CLOSED T K ONE ITEM ❑2 INTERIM PERMIT .❑4 AMENDED E IT ❑ 6 TEMPORARY TANK CLOSURE 08TANKREMOVED Q J FACILITY/SITE NAME WHERE TANK IS INSTALLED: � FARM TANK-YES NO ❑ I 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A OWNERS TANK IDR B. MANUFACTURED BY: C. YEAR INSTALLEg D. TANK CAPACITY IN GALLONS: )S 11. TANK TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),JS NOT MARKED,COMPLETE ITEM D. A. E�rl MOTOR VEHICLE FUEL ❑2 PETROLEUMC. 1 UNLEADED 2 LEADED ❑ 3 DIESEL F-13 CHEMICAL PRODUCT 0 4 OIL B. 1 PRODUCT ❑4 GASAHOL 5 JET FUEL 6 AVIATION GAS ❑5 HAZARDOUS E] 80 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 8 C.A.S.R C.A.S.R: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESSSTEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER C.INTERIOR F-1I RUBBER UNED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 OLASSUNING ❑6 UNLINED �95 NKNOWN ❑IS UNING MATERIAL COMPATIBLE WITH I00%METHANOL? ❑YES [:] NO �THER D.CORROSION ❑ 1 POLYETHIENE WRAP ❑2 TAR OR ASPHALT ❑ 3yjNYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑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 I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A .0 95 UNKNOWN A U 99 OTHER / S.CONSTRUCTION A U I SINGLEWALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER I' A U I STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGIASSPIPE A U 91 NONE N MATERULA 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 U 95 UNKNOWN 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 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 6 99 OTHER VI. NFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/Yfl) 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 TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY t COUNTY M JURISDICTION R nnAGENCY R FACILITY ID R TANK ID R � 1 1 Z�jw�l I'!::� 6 O r CURRENT LOCAL AGENCY FACILITY IDR / APPROVED BY NAME PHONE WITH AREA CODE P ERMITR - PERMIT APPpOVAL DATE PERMIT EXPIRATION DATE PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT9 BY: ^ A FORM B(6-29-8a) THIS FORM MUST BE ACCOMPANI _ A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RRENT FORMA' NAS BEEN FILED DATA PROCESSING COPY