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4 M^W l 1191 Ir l _, rN7f9` STATE OF CALIFORNI WATER RESOURCES CONTROI -)ARD FORM `B': UNDE ROUND STORAGE TANK PROGRAM TAN K / / TANK PERMIT APPLICATION INFORMATION m (/ COMPLETE A SEPARATE FORM WITH THE FOLLOWING JNFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED T K ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: -7 , �. FARM TANK - YES ❑ NO 7s N I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. OWNERS TANK ID k B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1). IS NOT MARKED. COMPLETE ITEM D. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, a D A. TYPE OF A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL SYSTEM ❑ 2 SINGLE WALLED ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW) ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF ❑ 8 100% METHANOL COMPATIBLE FRP U 1 STEEL/IRON HAZARDOUS SUBSTANCE STORED & C.A.S. # C.A.S. #: ❑ 10 GALVANIZED STEEL III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, a D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER B. CONSTRUCTION ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE F-] 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FRP U 1 STEEL/IRON 9 BRONZE ❑ 10 GALVANIZED STEEL [-] 95 UNKNOWN 99 OTHER 4 FIBERGLASS PIPE A U 91 NONE ❑ 1 RUBBER LINED F-]2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOUC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNLINED 8 100% METHANOL COMPATIBLE FRP ❑ 95 UNKNOWN A ❑ SLIMING MATERIAL COMPATIBLE WITH 100% 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 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 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 INERT MATERIAL? D YES ❑ NO GALLONS 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 N AGENCY R FACILITY ID S TANK ID N I L To CURRENT LOCAL AGENCY FACILITY ID N _ APPROVED BY NAME PHONE N WITH AREA CODE CAZ� LPERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE lm X PERMIT AMOUNT SURCHARGE AMT. FEE CODE CECEIPT N BY: FORM B (6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A', UNLESS A CURRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY