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STATE OF CALIFORNI WATER RESOURCES CONTRO AHD I UNDERGROUND STORAGE TANK FIR -1 FORM 'B': ry TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 10 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑7 P RMANENTLY CL MARK ONLY ❑ ❑q AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE B TANK REMOVED D N ONE ITEM ❑ 2 INTERIM PERMIT FARM TANK-YES NO FACILITY/SITE NAME WHERE TANK IS INSTALLED: L w I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 00 0 B. MANUFACTURED BY: A. OWNERS TANK ID# D. TANK CAPACITY IN GALLONS: 0 vv C.YEAR INSTALLED II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ER ED ITE LEADED ❑ 3 DIESEL A. ©1 MOTOR VEHICLE FUEL ❑ B.2 PETROLEUM rl�.PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑3 CHEMICAL PRODUCT ❑4 OIL L✓I 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) ❑ 5 HAZARDOUS ❑80 EMPTY E]95 UNKNOWN ❑2 WASTE ❑ D. IF NOT MOTOR VEHICLE FUEL,ON. NAME OF C.A.S.#: HAZARDOUS SUBSTANCE STORED&C.A.S.k III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,&D A.TYPE OF ❑1 DOUBLE WALED L ❑3 SINGLEWALLED WITH EXTERIOR LINER E]95 UNKNOWN SYSTEM k2SINGLEWALLED ❑4 SECONDARY CONTAINMENT [:]99 OTHER K�l1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE F-16 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN 99 OTHER ❑ I RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC UNING C.INTERIOR �UNUNED ❑95 UNKNOWN LINING ❑5 GLASS LINING F-1ISLINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO �990THEA D. CORROSION ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT ❑3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION �NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A 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 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A IJ�5 ALUMINUM 'A: U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A/� 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER RY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMA p i VISUAL CHECK 8 2 INVENTORY RECONCILIATION 3 VADOSE WELLS P 8' 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS PRECISION TESTING P S 7 PRESSURE TESTING •' P 91 NONE P S 95 UNKNOWN P S 99 OTHER BVI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS KFILLEDWITH 1. ESTIMA EO DATE LAST USED(MO/YR) 2.ESTIM ED QUANTITY OF BRT ERIAL? ❑YES E] NO SU EREMAINING IN GALLONS THI FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST.OF MY KNODWTE DGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY FACILITY ID% TANK ID# COUNTY# JURISDICTION# AGENCY# F07=O B b 1 APPROVE BY •NAME PHONE k WITH AREA CODE CURRENT LOCAL AGENCY FACILITY ID k , �y APPROVAL DATE PERMIT PIRATION DATE PERMIT NUMBER PERMIT CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: N4) FORMB(6-29-88) THIS FORM MUST BE ACCOMPANILu YAFACILITYDATA PPROCESSING COPYA',UNLESS ENT FORMA' HAS BEEN FILED