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STATE OF CALIFORNWATER RESOURCES CONTR' 30ARD FORM 'B': UND, GROUND STORAGE TANK PROGRAM -o. ''� TANK PERMIT APPLICATIONINFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWjNG INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYIn ED T NK ONE ITEM El2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CL URE ❑ B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 7 5-�� FARM TANK - YES ❑ NO ANK DESCRIPTION COMPLETE ALL ITEMS- IF UNKNOWN -SO SPECIFY V�✓ A. OWNERS TANK ID # B. MANUFACTURED BY: Xm5 C. YEAR INSTALLED 1 CA p D. TANK CAPACITY IN GALLONS: TANK CONTENTS IF /A-11- IS YARKFn CnYPI FTF ITFU C IF /A 11 IC .11 UA.v I-- -.—A A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. ❑ I DOUBLE WALLED C. ❑ 1 UNLEADED F]2 LEADED F-]3 DIESEL ❑ 3 CHEMICAL PRODUCT E]4 OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS El HAZARDOUS E] 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. 1 C.A.S. q: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A. B. C. & D A. TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER A U 95 UNKNOWN A U 99 OTHER ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS E]4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL WMPATI8LE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINED U 6 CONCRETE ❑ 95 UNKNOWN U ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION E] 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRC[ F A IF ARnvF r,Rnl wn I I IF I INnr:m(]R()I IAI1l n!%TN IC Anni I^An# C 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 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH 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 C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/ FRP A U 8 100% 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 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 S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 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 [:]NO I HIS hUHM 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 M JURISDICTION N AGENCY K FACILITY ID M TANK ID N l o� rRRENT LOCAL AGENCY FACILITY ID YAPPROVED BY NAME PHONE 0 WITH AREA CODE � PERMIT NUMBER PERMIT APPROVAL DATEPERMIT EXPIRATION DATE i zea CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE EIPT M BY: / /�-5 FOHM B (6-29-86) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM `A', UNLESS A CURRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY • Q