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STATE OF CALiFORN10 WATER RESOURCES CONTRO ARD UND STORAGE A Y FORM `B': UNDERGRO TANK PERMIT APPLICATION INFORMATION TAN COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z MARK ONLY Q 1 NEW PERMIT Q 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM2 INTERIM PER �4 AMENDED PERMIT p 6 TEMPORARY TANK CLOSURE TANK REMOVED Lo t N /1 FARM TANK-YES❑ NO W FACILITY/SITE NAME WHERE TANK IS INSTALLED: L1 ((� 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY C7? A. OWNERS TANK ID# -7 B. MANUFACTURED BY: i h C, YEAR INSTALLED D. TANK CAPACITY IN GALLONS: It. 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 PETROLEUM B. C. 0 1 UNLEADED E] 2 LEADED 3 DIESEL 3 CHEMICAL PRODUCT �A OlL EPl""PRODUCT El 4 GASAHOL ❑ 5 JET FUEL 6 AVIATION GAS 5 HAZARDOUS F-1 80 EMPTY [_] 95 UNKNOWN ❑ 2 WASTE El 7 METHANOL Ej44 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF � C.A.S.#: (� HAZARDOUS SUBSTANCE STORED&C.A.S.III III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF Q 1 DOUBLE WALLED F-] 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM �2 SINGLE WALLED E-1 4 SECONDARY CONTAINMENT 99 OTHER STEELIIRON El 2 STAINLESS STEEL F] 3 FIBERGLASS 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE F-] 7 ALUMINUM 8 10096 METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE F-] 10 GALVANIZED STEEL 0 95 UNKNOWN 99 OTHER 1 RUBBER LINED F-] 2 ALKYD LINING El EPDXY LINING El PHENOLIC LINING C. INTERIOR LINING F--] 5 GLASS LINING F-�6 UNLINED Fe�95 UNKNOWN El IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 99 OTHER D.CORROSION F-1 I POLYETHLENE WRAP 2 TAR OR ASPHALT ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION Q 5 CATHODIC PROTECTION E] 91 NONE 295 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 U 5 UNKNOWN A U 99 OTHER A U i STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A V 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W7FRP A U 8 100%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. t' P S 3 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P S 3 VAOOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS I r P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER. V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) Z. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH - AgNING IN INERT MATERIAL? YES NO SUBSTANCE HEM GALLONS 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 FCURRENT JURISDICTION# AGENCY# FACILITY ID# TANK ID# IT I I I L-1 LL I I ILL ol / I rl 16 BI Lo Lo ENCY FACILITY ID# APPROVED BY NAME PHONE k WITH AREA CODE Q c- o ! 1ILl��'-+ PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE I CHECK k--TPERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT k BY: )RMB(6-29-86) THIS FORM MUST BE ACCOMPANIOW A FACILITYISITE APPLICATION, FORM 'A',UNLESS A RENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY