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STATE OF CALIFORNIh WATER RESOURCES CONTRO OARD " FORM `B" UNDE ROUND STORAGE TANK PRAM TANK PERMIT APPLICATION INFORMATION 1 COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. °" 11 TANK 0 MARK ONLY F] 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ;jt- K REMOVED ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE w -T FARM TANK-YES ❑ N FACILITY/SITE NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN SO SPECIFY N A. OWNERS TANK ID# S B. MANUFACTURED BY: . S(o D. TANK CAPACITY IN GALLONS: CYEAR INSTALLED II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. B LEADED ❑2 LEADED ❑3 DIESEL A. 1 MOTOR VEHICLE FUEL D 2 PETROLEUM ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ❑ ❑ ❑ ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM 0,BELOW) 5 HAZARDOUS 80 EMPTY ❑ 95 UNKNOWN 2 WASTE D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF . C.A.S.#: HAZARDOUS SUBSTANCE STORED&C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED 4 SECONDARY CONTAINMENT99 OTHER 1 STEEUIRON q2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD WIFIBERGIASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ B 100%METHANOL COMPATIBLE FRP ` MATERIAL ❑9 BRONZE _ ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑5 GLASS LINING ❑6 UNLINED �NKNOWN LINING t L ❑ I6 LINING MATERIAL COMPATIBLE WITH 100%METHANOL? DYES ❑ NO .❑BOTHER D. CORROSION ❑ I POLYEfHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE �9/5 UNKNOWN ❑99 OTHER IV. PIPING INFORMA N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE U UNKNOWN A U 99 OTHER A U / STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U B 10096METHANOE COMA UIBLEFRP ONE C. MATERIAL A U 5 ALUMINUM A CONCRETE A U ] STEEL CLAD W/FRP A U 9 GALVANIZED STEEL A U 5 UNKNOWN A U 99 OTHER V. LEAK DETECTION YSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 5 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISIONTESTIN P S 7 PRESSURETESTING P 8 91 NONE P 5 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3. WAS TANKFILLEDWITH 1. ESTIM TEO DATE LAST USED IMO/VR) .ESTIMATED QUANTITY OF INERT MATERIAL? [:]YES ❑ NG SUBSTANCE REMAINING IN 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) LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# APPROVED----ME, (�'� Q PHONE N WITH AREA CODE FCHECK# CAL AGENCY FACILITY IDp � C �� BER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM S(6-29-w) THIS FORM MUST BE ACCOMPANIED BY A FACILITYDATAPPLIO TION, FORM A ',UNLESS 4 CURRENT FORMA' HAS BEEN FILED