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STATE OF CALIFORN WATER RESOURCES CONTR OARD FORM 'B': UND GROUND STORAGE TANK PROR RAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ej<5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED rw FACILITY/SITE NAME WHERE TANK IS INSTALLED: 1 t FARM TANK - YES ❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN — SO SPECIFY A. OWNERS TANK ID # — ( B. MANUFACTURED BY: N C. YEAR INSTALLED 5 D. TANK CAPACITY IN GALLONS: 80VO II. TANK CONTENTS IF (A.U. IS MARKED. COMPLETE ITEM C. IF (A.11. IS NOT MARKED- COMPLETE ITEM D_ A• ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C 1 UNLEADED 2 LEADED 3 DIESEL ❑ 3 CHEMICAL PRODUCT 04 OIL �K1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL �9 OTHER (DESCRIBE IN ITEM D, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF HAZARDOUS SUBSTANCE STORED & C.A.S. # (� L C.A.S. #� x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER U 1 SINGLE WALLED A U 2 DOUBLE WALLED F-11 STEEL/IRON 2 STAINLESS STEEL F-]3 FIBERGLASS F-14 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FRP C. MATERIAL 9 BRONZE 10 GALVANIZED STEEL 2�195 UNKNOWN ❑ 99 OTHER A U 8 100% METHANOL COMPATIBLE FRP F-11 RUBBER LINED El2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNLINED b;;�f95 UNKNOWN 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 ❑ 91 NONE 5?'95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE A (Q 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A OU 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 C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLADW/FRP A U 8 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A CD 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 2 SUBSTANCE REMAINING IN _ INERT MATERIAL? Ej YES 40 a.,. ` 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 # EE I I I I AGENCY # EI I I I -In FACILITY ID # 10 1116 1 2 TANK ID # D 1 T-0-fil— CURRENT LOCA AGENCY FACILITY ID # APPR ME PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATEPv [ ERMIT EXPIR TION DATE CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT # BY: FORM B (3-7-88) THIS FORM MUST BE ACCOMPA -M BY A FACILITY/SITE APPLICATION, FORM 'A', UNLE6WtURRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY z 1 @!