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STATE OF CALIFORN16 WATER RESOURCES CONTRWOARD FORM 'B': UND GROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION ° ti 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 PE MANENTLY CLOSED ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED Q� FACILITY/SITE NAME WHERE TANK IS INSTALLED: 4 FARM TANK-YES❑ NO / (� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY N N A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED ct LLONS:D. TANK CAPACITY IN GA 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 OLEUM B. C, ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL -13 CHEMICAL PRODUCT 4 OIL ❑ 1 PR LOT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN WASTE ❑7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF A HAZARDOUS SUBSTANCE STORED 8 C.A.S.# - C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A. TYPE OF ❑jDOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SI EWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL F-] 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑810D%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR F-] 1 RUBBER LINED ❑2 ALKYD LINING F-] 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING �NLINED ❑!VNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH In METHANOL? ❑YES ❑ NO Rrg9 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑2 TARORASPHALT ❑ 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 UNDE ROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A(UD 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 i STEELARON A U 2 STAINLESSSTEEL 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 W/FRP A U 8100%METHANOL COMPATIBLE FRP A®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. Y1 P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 1✓" P S 6 PRECISION TESTING P S 7 PRESSURE TESTING 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMA ED DATE LAST USED(MO/YR) 2. ESTIM TED QUANTITY OF 3. WAS TANK FILLED WITH A / .[� S11R� EREMAINING IN GALLONS IN RT ERIAL? E:]YES ❑ NO /` � THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWL DGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# = 6 10 11 ? 5 3 O D D CURRENT LOCAL A ENCY FACILITY ID# APPROVED BY NAME ` PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE l CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: V� FORM B(6-29-66) THIS FORM MUST BE ACCOMPANIh A FACILITY(SITE APPLICATION, FORM 'A',UNLESS A ENT FORMA' HAS BEEN FILED DATA PROCESSING COPY