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STATE OF CALIFOR WATER RESOURCES CONT OARD �b.`.a:; roe. Y FORM `B': UNDEGROUND STORAGE TANK PR AM x '� - • TANK TANK PERMIT APPLICATION INFORMATION '® COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL K ONE ITEM ❑ 2 INTERIM PERMIT El AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED t N FACILITY/SITE NAME WHERE TANK IS INSTALLED; fI 72—0 � (/Q� L FARM TANK-YES❑ NO 4bb I. TANK DESCRIPTION COMPLETE ALL ITEMS-If UNKNOWN—SO SPECIFY —4 A. OWNERS TANK ID# B. MANUFACTURED BY: 42IIb C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Iq 0 0 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 ❑ PETROLEUM B. C. ❑ 1 UNLEADED [:] 2 LEADED ❑ 3 DIESEL F-] 3 CHEMICAL PRODUCT L V 14 OIL 2f1 PRODUCT ❑ 4 GASAHOLV99110TTHER FUEL 5 AVIATION GAS [:] 5 HAZARDOUS ❑ BG EMPTY [:] 95 UNKNOWN 7 METHANOL (DESCRIBE IN ITEM D,BELOW) 2 WASTE / �,/ �J D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S. - 1 6j ✓ HAZARDOUS SUBSTANCE STORED&C.A.S.# Q III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OFOUBLE WALLED F—] 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM V2)51NGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER EV STEELMON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE FRP MATERIAL ®9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER F—] 1 RUBBER LINED ❑ 2 ALKYD LINING F__] 3 EPDXY LINING V95 HENODC LINING LINING C. INTERIOR F__] 5 GLASSUNING F—] 6 UNLINED UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENEWRAP ❑ 2 TAR OR ASPHALT V-195 VINYLWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION [:] 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ 99 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 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 A U J95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W1 FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. 65AK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# � y J ua 1 � I CURRENT LOCAL ADEN AGILITY ID# APPROVEDMM PHONE#WITH AREA CODE a PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION D E (i CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE *RECEIPT# BY: JvFORM B(6-29-BB) THIS FORM MUST BE ACCOMPANI A FACILITYISITE APPLICATION, FORM 'A',UNLESNT FORMA' HAS BEEN FILED DATA PROCESSING COPY