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STATE OF CALIFORN WATER RESOURCESCONTROARD FORM `B': LAND GROUND STORAGE TANK PRO RAM ` TANK TANK PERMIT APPLICATION INFORMATION m COMPLETE A SEPARATE FORM WITH THE FOLLOWINg INFORMATION FOR EACH TANK. __- Z 10 MARK ONLY ❑ 1 NEWPERMIT L] 3 RENEWALPERMIT 125 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIMPERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO (� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY N A. OWNERS TANK IDN B. MANUFACTURED BY: C. YEAR INSTALLED 1A X I D. TANK CAPACITY IN GALLONS: zi I1. TANK qqNTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A EfirMOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL F-13 CHEMICAL PRODUCT ❑4 OIL /' 1 PRODUCT ❑ 4 GASAHOL 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY a15UNKNDAN 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.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ 1 DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEELPRON ❑ 2-STAINLESS STEEL •❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 A INUM ❑81W%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL E�j<UNKNOWN �9 OTHER U F__] I RUBBER LINED ❑ 2 ALKYD LINING F__] 3 EPDXYLINING E]4 PHENOLICUNING C. INTERIOR 5 GLASS UNING 6 UNLINED 5 UNKNOWN LINING ❑ ❑ Lam'°' ❑ ISLINING MATERIAL COMPATIBLE WITH 10896 METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, 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 SINGLEWALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUMA U 6 CONCRETE A U 7 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL U 5 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 t VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING S 91 NO P S 95 UNKNOWN P 8 99 OTHER , VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES E] 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 COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENOCALA ENCY FA ILITY ID# APPROVED BYN M PHONE WITH AREA CODE Q L r1Y�JG,7L 16-IA PERMIT NUMBER PERMIT APPROVAL OA PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT _r SURCHA AMT. FEE CODE RECEIPT# BY: F M 8(6-29-66) THIS FORM MUST BE A OMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A",UNLESS A CURRENT�'A' HAS BEEN FILED <� DATA PROCESSING COPY / 1