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STATE OF CALIFORNIt WATER RESOURCES CONTRO ARD FORM 'B': UNDE ROUND STORAGE TANK PROMAM P � ..' <s TANK TANK PERMIT APPLICATION INFORMATION m' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. o MARK ONE ITEM OE]/ ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT - ❑ 7 PERMANENTLY CLOSED TANK ❑ 6 TEMPORARY TANK CLOSURE ❑S TANK REMOVEC2 FACILITY/SITE NAME WHERE TANK IS INSTALLED: 7Y31 4.). L 1 " m/ K O' /I1 FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN- 50 SPECIFY i A. OWNERS TANK ID S _ LIV B. MANUFACTURED B C. YEAR INSTALLED 7 D. TANK CAPACITY IN GALLONS: CO II. TANK CO TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. S W A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B® C. ❑ 1 UNLEADEDLEADED ❑ 3 DIESEL 9 ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT �/' ❑4 GASAHOL ❑5 JET FUEL E] 6 AVIATION GAS El HAZARDOUS F--] 80 EMPTY g5 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ I DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM U ' ©SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER B.TANK I STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑5 CONCREFE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 1M%MFTHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED 2 ALKYD LINING � C. INTERIOR-� ❑ ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING /(p ❑ 5 GLASS LINING UNLINED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL 77 ❑YES 21 NO ❑ 99 OTHER 0. CORROSI ❑ I POLYEIHLENE WRAP ❑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 IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE /9 A U 1 SUCTION A U PRESSURE A U 3 GRAVITY 9 OTHER B. CONSTRUCTIO A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STA INLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 9 GALVANIZED STEEL A195 UNKNOWN A U 99 OTHER A U 8100%METHANOL COMPATIBLE FRP yZ V• DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. S 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER -/�/L, VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1,90/1 SHMATED DATE LAST U.SED/(MO/YR) , ESTIMATED OUANTITV 'F /1 / SUBSTANCE REMAINING IN - 3. WAS TANK FILLED WITH ii',,,VVV GALLONS INERT MATERIALP DYES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY y COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 3y o o I UU CYPENT LOCAL AGENCY FACILITY IDN APPiPY ED BY NAME T /�/ PHONE#WITH AREA CODE PERMIT NUMBER �� MITAPPROVALDATE PERMIT %PIR ION DATE \ ou CHECK# PERMIT AMOUNT gCHARGE AMT. FEE CODE J RECEIPT# BY: ORM B(3-7-BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A C RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY