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WATER RESOURCES CONTR OARD STATE OF CALIFORNIA UND GROUND STORAGE TANK PRAM ' RM `B': INFORMATION FO TANK PERMIT APPLICATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. S CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK El3 RENEWAL PERMIT ❑ W8 TANK REMOVED MARK ONLY El1 NEW PERMIT ❑q AMENDED PER ❑6 TEMPORARY TANK CLOSURE d ONE ITEM ❑2 INTERIM PERMIT FARM TANK-YES❑ NO z FACILITY/SITE NAME WHERE TANK IS INSTALLED: 10 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SBE IIFY ANUFACTUREDBY: uK A. OWNERS TANK ID M /V h6e D. TANK CAPACITY IN GALLONS. 04 V' C.YEAR INSTALLED IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,CU UNLEADED ITEM 2 LEADED E]3 DIESEL C. IB' A. � 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM /, PRODUCT ❑q GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑3 CHEMICAL PRODUCT ❑ 4 OIL IL LJJJ T METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) F-15 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE 11 D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: HAZARDOUS SUBSTANCE STORED&C.A.S.# All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D ❑3 SNGLEWALLFD WITH EXTERIOR UNER 95 UNKNOWN A TYPE OF Fl DOUBLE WALLED ❑99 OTHER SYSTEM �2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK F-�5 CONCRETE 6 POLYVINYLCHLORIDE F� 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FAP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER F-1 1 UBB81 LINED ❑2 ALKYD LINING ❑3 EPDXY LINING 0 4PLINING C. INTERIOR ❑5 RUBEGSSUNING ❑6 UNUNED j' UNKNOWN LINING ❑ IS UNING MATERIAL COMPATIBLE WITH I DO%METHANOL? ❑YES ❑NO E]99 OTHER POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC D.CORROSION ❑ 1 PROTECTION ❑5 CATHODICPROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV, PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLIUABLOTHER A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3lINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POTEELCLAL CHLORIDE HLORRID EIPVC) A U 4 FIRE METHANOL COMPATIBLE FRP FIFE A U 5 ALUMINUM A �B CONCRETE C. MATERIAL A U 9 GALVANIZED STEEL A[N•L•JIO•5 UNKNOWN A U 99 OTHER V.t:::::H DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. RONIC ECK P S 2 INVENTORY RECONCILIATION p 5 3 VADOSE WELLS Y 8 95EUNKNOWN LECTRONIC MONITOR V 8 S�GOROHE D WATER MONS N TESTING P S T PRESSURE TESTING p S 91 NONE' VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3 WAS TANK FILLED WITH 2. ESTIMATED QUANTITY OF INERT MATERIAL? YES NO 1.ESTIMATED DATE LAST USED(MO/VR) SUBSTANCE REMAINING IN GALLONS PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT THIS FORM HAS BEEN COMPLETED UNDER APPLICANT'S NAME(PRINTED&51GNA I URE) LOCAL AGENCY USE ONLY TANK ID# kPERMITNUMBER JURISDICTION# AGENCY# FACILITY ID# = HEED= APPROVED Y NAME PHONE#WITH AREA CODE GENCY FACILITY IQ (� 89"y1e, PERMIT APPROVAL DA E PERMIT EXPIRATION DATE FEE CODE RECEIPT# BY: CHECKk PERMIT AMOUNT SURCHARGE AMT. 'W1I FORM B(3-7-R&) THIS FORM MUST BE ACCOMPANIED o A FACILITY/DDA APPLICATION,OESS NOGRCOPA`,UNLESS A C „ENT FORMA' HAS BEEN FILED