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STATE OF CALIFORM& WATER RESOURCES CONT�OARD "`• FORM `B': UND GROUND STORAGE TANK PR RAM . TANK TANK PERMIT APPLICATION INFORMATION y COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. I O MARK ONLY ❑ HANGE OF INFORMATION 7 PERMANENTLY CLOSED TAN 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED I � FARM TANK-YES❑ NO no FACILITY/SITE NAME WHERE TANK IS INSTALLED: N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN SO SPECIFY y B. MANUFACTURED BY: A. OWNERS TANK IDR .J C. YEAR INSTALLED t1}� D. TANK CAPACITY IN GALLONS: 10 ,960 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. [D,Y-60TOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(D-ESC/RIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OFC.A.S.#: HAZARDOUS SUBSTANCE STORED&C.A.S.R A III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,&D A TYPE OF 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER ❑ 1 RUBBER UNEO 2 AUKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING C.INTERIOR ❑ 6 UNUNED 95 UNKNOWN LINING 5 GLASS UNING F-1IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO 99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFAB a GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A 1 SUCTION A V2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 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 U 5 ALUMINUM A X,,6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 /00%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A(9 95 UNKNOWN A U 99 OTHER LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 5� P IVISUAL CHECK P S 2INVENTORYRECONCILIATION P S 3VADOSEWELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS 6 PRECISION TESTI# S 7 PRESSURETESTING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIM EDDATE LAST USED(MO/YR) 2.ESTIM TED QUANTITY OF 3. WA TANK FILLED WITH B AKCE REMAINING IN GALLONS IN MATERIAL? E]YES E] NO Y L THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO LEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# E DD b' o? Io 10 CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NA E PHONE#WITH AREA CODE tv/4 /0 PERMIT NUMBER PERMIT APPROVALDATE R ITEX IRATION DATE CHECK# PERMITAMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-BB) THIS FORM MUST BE A70MPANI .A FACILITY/SITE APPLICATION, FORM'A',UNLESS A PENT FORMA' HAS BEEN FILED \ DATA PROCESSING COPY