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�e'71PfA#�'.'Pj•2r"""9F�'.'IPlT• . , - STATE OF CALIFORNI& WATER RESOURCES CONTRq&OARD FORM B': LAND GROUND STORAGE TANK PRO RAM TANK TANK PERMIT APPLICATION INFORMATION c m 2 COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY D All ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVE L/ GN FACILITY/SITE NAME WHERE TANK IS INSTALLED: 2 � W, FAflM TANK-YES❑ NO IV I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERSTANKID# 6 B. MANUFACTUREDBY: W C. YEARINSTALLED D. TANK CAPACITY IN GALLONS: 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 B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT [ OIL ❑ 1 P ODUCT ❑ 4 GASAHOL ❑ FUEL ❑ 6.AVIATION GAS ❑5 HAZARDOUS ❑ 00 EMPTY ❑95 UNKNOWN 2 WASTE ❑ 7 METHANOL 99 OTjHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF A HAZARDOUS SUBSTANCE STORED&CAS.# (�/� C.A.S.#: V III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXA.B,C,BD A.TYPE OF ❑ 1 D UBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASSREINFORCEDfWIIC 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-11 RUBBER LINED ❑ 2 ALKYD LINING F7 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ S GLASS LINING LINED ❑ UNKNOWN' A/! ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES 0N ff99 OTHER v�✓•_ D. CORROSION ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT ❑3 VINYLWRAP ❑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 ASUCTION A U 2 PRESSURE A U GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 k1NKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM ACONCRETE A U ]STEEL CLAD W/FRP A U S 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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 S i VISUAL CHECK 52S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P PRECISION TESTING P 8 7 PRESSURETESTING P 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAS USED(MO/YR) 2. ESTIMATED O TITY OF S WAS TAN T��R�E"D WITH SUBSTANC :WING IN INE i,tpBlt7 ❑YES ❑ NO GALLONS T, ``// THIS FORM H S BEEN COMPLETED UNDER PENALTY OF 9ERJURY,AND TO THE 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# ® = = lolol ;T6- 131oldD c) t CURRENT LOCAL AGENCY FACILITY ID# APP9QVED BY NAMA PHONE#WITH AREA CODE CA- l7- I PERMIT NUMBER PERMIT APPROVAL DATE I PERMITEXPIRATION DATE 1 CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT p BY: FORM B(6-29-BS) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED 1-5 DATA PROCESSING COPY