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STATE OF CALIFORNI4S WATER RESOURCES CONTRO ARD FORM `B': UNDE ROUND STORAGE TANK PRO AM �® TANK TANK PERMIT APPLICATION INFORMATION „ COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. " ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLYCL SEDT NK 1 NEW PERMIT ❑3 RENEWAL PERMIT I le' ANK REMOVED Q MARK ONLY ❑ ❑6 TEMPORARY TANK CLOSURE ua_ ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT FARM TANK-YES❑ NO FACILITY/SITE NAME WHERE TANK IS INSTALLED: G O 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SBM SPECIFY BY: W A. OWNERS TANK ID# n1-0 e D. TANK CAPACITY IN GALLONS' C.YEAR INSTALLED 11. TANK CONTENTS IF(A 1j,IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. B C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ r77 A. ❑1 MOTOR VEHICLE FUEL 2 PETROLEUM 3 DIESEL [:] ❑ 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL E]6 AVIATION GAS � ❑3 CHEMICAL PRODUCT LJ"'L �ASTE ❑7 METHANOL OTHER(DESCRIBE IN ITEM D,BELOW) ❑5 HAZARDOUS ❑ BO EMPTY ❑95 UNKNOWN L.p` V D # D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF � � f �,L� HAZARDOUS SUBSTANCE STORED&C.A.S.# W Q 5m D All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,&D ❑3 SINGLE WALLED WITH IXTERIORUNER ❑95 UNKNOWN A ENT TYPE OF F-1 I DOUBLEWALLED ❑99 OTHER SYSTEM 2 &t SYSTEM ❑4 SECONDARY CONTAINM ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEELCIADWIFIBERGLASS REINFORCED PLASTIC CONCRETSTEBUIROE fi POLYVINYLCHLORIDE F-1 T ALUMINUM ❑B 10095 METHANOL COMPATIBLE FRP B.TANK F1 5 CONCRETE ❑ MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑1 RUBBER LINED ❑27 D UNING ❑3 EPDXY LINING ❑4 PHENOLIC LINING C.INTERIOR UNLINED ❑95 UNKNOWN LINING ❑5 CUBS UNING 99 OTHER ❑ IS UNING MATERIALCOMPATIBIEWITH 100%METHANOL? E]YES ❑NO E] D.CORROSION ❑ 1 pOLYETNUNEWRAP ❑2 TAR OR ASPHALT ❑3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION F:aONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLOTHER A SYSTEM TYPE A u 1 SUCTION A U 2 PRESSURE A U 3 RAVITY B.CONSTRUCTION A l SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER PE A 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) R U 6100%METHANOL COMPATIBLE FRP C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/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. p S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION p S 3VNONEEWELLS P $ 95ELECTRONIC MONITOR UNKNOWN P 9 9GROUNDWATER MONITORING WELLS 99 OTHER arY�- p S 6 PRECISION TESTING P S 7 PRESSURE TESTING p VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLED WITH 1. ESTIMATED 2. ESTIMATED QUANTITY OF INERT MATERIAL? ❑YES ❑ NO ,�1 DATE LAST USED(MO/YR) SUBSTANCE REMAINING IN GALLONS 'THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO FHE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) LOCAL AGENCY USE ONLY TANK ID# COUNTY# JURISDICTION# AGENCY a FACILITY ID# `//'� IIIc- LILT I1I�III oo l a q � � ao �- r I�� PHONE k WITH AREA CODE APPROVED BY NAN CURRENT LOCAL AG FACILITY ID#� PERMIT APPROVAL DAIS O PERMIT EXPIRATION DATE PERMIT NUMBER RECEIPT BY: CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE FORM B(3-7-66) THIS FORM MUST BE ACCOMPANIEDIn FACILITYISIPROCESSING OG A,,UNLESS A C HENT FORMAHAS BEEN FILED OAAOPY