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STATE OF CALIFORNIO WATER RESOURCES CONTRWOARD FORM 'B': UNDERGROUND STORAGE TANK PRd5RAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ®' MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT � C ONE ITEM u 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYC TP„' ❑2 INTERIM PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN- D Col FARM TANK-YES❑ NO A. OWNERS TANK ID# SO SPECIFY C D. MANUFACTURED BY: C. YEAR INSTALLED LAWA D. TANK CAPACITY IN GALLONS Ob If. TANK CONTENTS IF(A,1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A 11� W Ill MOTOR VEHICLE FUEL ❑ 2 PETROLEUM FJ ❑3 CHEMICAL PRODUCT ❑ 4 OIL IL6. C. ❑ 1 UNLEADED ❑2 LEADED ql DIESEL ❑ BO EMPTY 95 UNKNOWN 2 WASTE CT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS 5 HAZARDOUS ❑ ❑ ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER HAZARDOUS SUBSTANCE STONAME OF RED&C.A.S.q 10 :111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,d D C.A.S.q A TYPE OF �❑�1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER SYSTEM E2°SINGLE WALLED ❑95 UNKNOWN 4 SECONDARY CONTAINMENT ❑gg OTHER S.TANK I STEEL/IRON 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑5 CONCRETE 6❑ POLYVINYLCHLORIDE ❑ 7 ALUMINUM IO GALVANIZED STEEL ❑810096 METHANOL COMPATIBLE FflP 9 BRONZE 010 ❑95 UNKNOWN 99 OTHER C.INTERIOR ❑ 1 RUBBERLINED ❑2 ALKYO LINING ❑3 EPDXYLINING ❑ 4 PHENOLIC LINING LINING ❑5 GLASSUNING �6 UNLINED ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑ UNKNOTHEOWN D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP E]9g PROTECTION ❑5 CATHODIC PROTECTION ❑gl NONE ❑4 FIBERGLASS REINFORCED PLASTIC B6 UNKNOWN 9g 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 B. CONSTRUCTION A U 1 SINGLE WALLED A A U 3 GRAVITY A U 99 OTHER U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U I STEEL/IRON A U 99 OTHER C. MATERIAL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 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. PS 1 VISUAL CHECK ®S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 5 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE P s ss OTHER 1. ESTIMATED D TE LAST USED(MO/YR) 2. ESTIMATED OU NTITY OF SUBSTAjICQR fyNINING IN 3_ WAS TANK FILLED WITH Al GALLONS INERT MATEWA 9 ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE REST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COODUNTT^YY## JURISDICTION# AGENCY# L-`-4—J FACILITY ID# TANK ID# S-- � OD p3 CURRENT LOCAL AGENCY FACILITY 10 M 00 / APPROVED .9K_ il �tPHONE#WITH AREA CODE S K PERMIT NUMBER PERMIT APPROVAL DATE 1 PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT URCHARGE AMT. FEE CODE CEIPT# BY: FORM B(3-7-BB) THIS FORM MUST BE ACCOMPANIED BTA FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY