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STATE OF CALIFORN� WATER RESOURCE.- CONTR OARD Go FORM 'B': UND GROUND STORAGE TANK PR RAMTANK TANK PERMIT APPLICATION INFO MATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING I RMATION FOR EACH TANK. Z MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK I ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHEREMANK IS INSTALLED: (/ w FARM TANK-YES❑ NO w I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN–SO SPECIFY cyl A. OWNERS TAw NK ID K ///'' B. MANUFACTURED BY: /,(e— (J7 C. YEAR INSTALLED GL G� D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUMB. C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑ 95 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.K C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,II D A. TYPE OF ❑ 1 qWkEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SING ❑4 SECONDARY CONTAINMENT ❑99 OTHER STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP I MATERIAL ❑ ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR I RUBBER LINED ❑2 LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING F-15 GLASS LINING 6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL9 ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ i POLYETHLENE WRAP ❑2 T ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION E]5 CATHODICPROTECTION 1 NONE ❑ 95 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 A U 99 OTHER B. CONSTRUCTION Ai;Lr�- L A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER U 1 STEFUIRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CUD W/FRP A U 8100%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. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING 91 NON P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE UST USED(MO/YR) 2. ESTIMATED QUANTITY OF TWATANK FILLED WITH SUBSTANCE REMAINING IN � � INERT MATERIAL? ❑YES ❑ NO O(1LLONS -- 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 COUNI--�f J JURISDICTION� AGENCY# FACILITY IDK TANK IDK CURRENT LOCAL AGENCY FACILITY ID K APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK K PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: FORMS(6-29-5a) THIS FORM MUST BE ACCOMPANIED BY. . CILITY/SITE APPLICATION, FORM 'A',UNLESS A CUR FORMANAS BEEN FILED DATA PROCESSING COPY