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IVO , Ij STATE OF CALIFORNIft WATER RESOURCES CONTRC OARD FORM 'B': UNDE GROUND STORAGE TANK PROGRAM W'T TANK TANK PERMIT APPLICATION INFORMATION - - -- - - - COMPLETE E A SEPARATE E FORM wI I n I nE rULLUwInu INFORM#%i lvn run EA%,rI 1 Alm :L MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 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 A. OWNERS TANK ID # 0 q B. MANUFACTURED BY: �� 7VL C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: S7Sb 11. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF MAL IS NOT MARKED, COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C• 1 UNLEADED E]2 LEADED 3 DIESEL ❑ 3 CHEMICAL PRODUCT OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JETfUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN L 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. # C.A.S. #: ' III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D A. TYPE OF [:]_IPOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER B. CONSTRUCTION STEEL/IRON F-]2 STAINLESS STEEL F-13 FIBERGLASS F-]4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B. TANK 5 CONCRETE 6 POLYVINYL CHLORIDE F-]7 ALUMINUM 8 100% METHANOL COMPATIBLE FAP MATERIAL 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 4 FIBERGLASS PIPE A U 91 NONE F-]1 RUBBER LINED E]2 ALKYD LINING F-13 EPDXY LINING F-14 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING 6 UNLINED 8 100% METHANOL COMPATIBLE FRP ❑ 95 UNKNOWN A ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO �J% OTHER D. CORROSION ❑ i POLYETHLENE WRAP 2 TAR OR ASPHALT 3 V L WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION [:]5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER IV. r'lr'IM%m lMrWrIMM I IVIM GIHGLt A II" ACUVt UriUUIVU, Y II' UIVUtmL2mu UIVU, 6V 1n Ir ArrL1l,A6LC A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A Wl 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(091 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 ALUMINUMA U �6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A / UU 95 UNKNOWN A U 99 OTHER FEE CODERECEIPT # 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 05 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED ATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH FACILITY ID # SUBSTANCE REMAINING IN INERT MATERIAL? Y ❑ NO ES I' IFAC�lTY GALLONS THIS F&M HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME (PRINTED & SIGNATURE) DATE 1 ACOL OrFNCY IISF ANLY FORM B (6-29-66) THIS FORM MUST BE ACCOMPANIEUM A FACILITY/SITE APPLICATION, FORM 'A', UNLESS ALTHRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY JURISDICTION # AGENCY # FACILITY ID # TANK ID # � I' IFAC�lTY CURRENT AGENCY ID # APPROVED BY PHONE #WITH AREA CODE EPERMITNUMBER r APP ALD T P RMIT EX IRATI N DATEPERMIT PERMIT AMOUNT SURCHARGE AMT. FEE CODERECEIPT # BY: FORM B (6-29-66) THIS FORM MUST BE ACCOMPANIEUM A FACILITY/SITE APPLICATION, FORM 'A', UNLESS ALTHRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY