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it�y+pii r�E STATS OF CALIFORNI WATER RESOURCES CONTRO ARD�* FORM 'B': UNDE ROUND STORAGE TANK PRO AM r� o TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. LJ MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TAN'T K ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED S� ' r+ FACILITY/SITE NAME WHERE TANK IS INSTALLED, FARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY v rIGc�PIvw A. OWNERS TANK ID# B. MANUFACTURED BY: L/ C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: )Q II. TANK CO NTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED CO ETE ITEM D. A. MOTOR VEHICLE FUEL F-12 PETROLEUM B. C.• 1 UNLEADE 2 LEADED E] 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL RODUCT AHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ BO EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER PESCRIBJE IN 11 ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: 1 11 # N HAZARDOUS SUBSTANCE STORED&C.A.S. III. TANK CONSTRUC N MARK ONE ITEM ONLY IN BOX A,B,C,&D 1 DOUBLEWALLED F-13 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN A,TYPE OF SYSTEM ❑ 2 SINGLE WALLED F] 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS STEELCLAO W/FIBERGLASS REINFORCED PLASTIC B.TANK 7--1 5 CONCRETE ❑6 POLYVINYLCHLORIDE I 0% �7 ALUMINUM ❑ 8 1CMETHANOL COMPATIBLE FRP MATERIAL El9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING G. I14TERIORF-1 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? ❑YES 0 ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP BERGLASS 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 A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A 2 DOUBLE WALLED A U 3 UNEDTRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE G. MATERIAL A U S ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD WI FRP A U B 100%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 VISUALCHECK 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 S 7 PRESSURE P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANKFILLEowITH 1. ESTIMATED DATE LVSEN O/YR) 2. ESTIMATED QUANTITY G I FINERT MATERIAL? ❑YES ❑ NO SUBSTANCE REMAINING IN GALLONS THIS FORM HAOMPLETED UNDER PENALTY OF PERJURY,AND TQ THE BEST OF MY KNOWLEDGE,!S TRUE AND CQRRECT. URE) DATE APPLkGANT'S NAME(PRINTED&51GNAT LOCAL AGENCY USE ONLY FACILITY ID# TANK ID# COUNTY# JURISDICTION# AGENCY# Ll I I APPROVED BY Nf 4) ME PHONE#WITH AREA CODE CURRENT LOCAL AGENCY FACILITY ID# PACIFIC Go PERMIT NUMBER PERMIT APPROVAL DATE ERMI EXPIRATIO DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT* BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIE Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A udRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY