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STATE OF CALIFORNI& WATER RESOURCES CONTROARD FORM `B+: UND ROUND STORAGE TANK PRO AM TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. TANK MARK ONLY ❑ 1 NEW PERMIT F-13 RENEWAL PERMIT g 5 CHANGE OF INFORMATION ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE FACILITY/SITE NAME WHERE TANK IS INSTALLED: �✓ I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN -SO SPECIFY A OWNERS TANK Oft3 B MANUFACTURED BY: /^ O. TANK CAPACITY IN GALLONS: Qpz ❑ 7 PERMANENTLY CLOSEDTANK ❑ 8 TANK REMOVED Q / FARM TANK - YES ❑ NO � W (A1), ISNOT MARKED, COMPLETE ITEM D. C. ❑ 1 UNLEADED LEADED 3 DIESEL �ODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C. & D C.A.S. #: A TYPE OF ❑ 1�UBlEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER G YEAR INSTALLED II. TANK C NTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. ❑ 4 SECONDARY CONTAINMENT A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL C ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN C TANK ID # D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF HAZARDOUS SUBSTANCE STORED & C.A.S. # O. TANK CAPACITY IN GALLONS: Qpz ❑ 7 PERMANENTLY CLOSEDTANK ❑ 8 TANK REMOVED Q / FARM TANK - YES ❑ NO � W (A1), ISNOT MARKED, COMPLETE ITEM D. C. ❑ 1 UNLEADED LEADED 3 DIESEL �ODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C. & D C.A.S. #: A TYPE OF ❑ 1�UBlEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN ❑ 99 OTHER SYSTEM 2 SINGLEWALLED ❑ 4 SECONDARY CONTAINMENT FACILITY ID # TANK ID # STESUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC PHONE #WITH AREA CODE B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 IXR6 METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER INTERIORF-1 ❑ 1 RUBBER LINED ❑ 2 ALKYD UNING ❑ 3 EPDXY UNING 4 PHENOLIC LINING UNKNOWN C. LINING 5 GLASS LINING ❑ 6 UNLINED METHANOL? ❑YES [D NO F7990THER ❑IS LINING MATERIAL COMPATIBLE WITH 10096 _ _ enou +w+ uw ccc D. CORROSION ❑ I POLYETHLENEWRAP ❑ 2 TAR OR ASPHALT F-1 ILWRAP ,� 5 UNKNOWN ❑ 4 FIBERGLASS REINFORCED PLASTIC ❑ 99 OTHER PROTECTION F-15 CATHODIC PROTECTION E]91 NONE IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. A U 91 NONE A U 95 UNKNOWN A U 99 OTHER CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U S ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL 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. 1 VISUAL CHECK O S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS Pp S PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI.;INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE3. WAS TANK FILLED WITH. ESTIMATED DATE LAST USED IMO/YR) 2. ESTIMATED QUANTITY OF INERT MATERIAL?❑ YES ❑ NO / T SUBSTANCE REMAINING IN GALLONS r/ 11 oro a lav Awn Tn THF RFST OF MY KNO WLEDGE, IS TRUE AND CORRECT V/ THIS F( IRM HAS BEEN CUMYLt I tv Urvucn rcl—„ -, ......... - - - - DATE APPLICANT'S NAME (PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # AGENCY # FACILITY ID # TANK ID # APPROVED BY NAME P PHONE #WITH AREA CODE CURRENT LOCAL AGENCY FACILITY IDX �� 32, PERMIT NU BER PERMIT APPROVAL DA PERMIT EXPIRATION DATE CMECKk PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: _ _ _ _ __ __ _ _ enou +w+ uw ccc a ,. Pu7 FORY'A' HAS BEEN FILED FORMB(6-29-88) THIS FORM MUST BE ACCUMPANICU�l A rAWLII naue nr�u...•�•�••, -••••• -- --- DATA PROCESSING COPY /..