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STATE OF CALIFORN& WATER RESOURCES CONTROARD FORM `B': UND GROUND STORAGE TANK PR RAM TANK TANK PkRMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 P RMANENT;�; OSED TANK 10 ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE TANK REMOV FACILITY/SITE NAME WHERE TANK IS INSTALLED: 3 , FARM TANK-YES NO N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 00 A. OWNERS TANK ID# B. MANUFACTURED BY: C.YEAR INSTALLED I D. TANK CAPACITY IN GALLONS: �D IL TANK CONTENTS IF(A. ,IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. _ A. ❑ 1 MOTOR VEHICLE FUEL F-12 P ROLEUM B. FEI ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMP ❑ 95 UNKNOWN ❑2 WASTE 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME F HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE IT ONLY IN BOX A,B,C,&D A.TYPE OF F-1-1 DOUBLE WALLED ❑3 SINGL ALLIED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDA CONTAINMENT ❑99 OTHER ❑1 STEEL/IRON ❑2 STAINLESS STE ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLOR E ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑1 RUBBER LINED ❑2 ALKYD LINING 3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR LINING ❑5 GLASS LINING ❑6 UNLINED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑ S ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VI WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC 5 PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 UNK WN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGR UND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 G VITY 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 LIN 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 POLYVI YL 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 C D 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 P IMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTR NIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNO 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 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY K WLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) ATE LOCAL AGENCY USE ONLY FPERmfrNUM-BEgR JURISDICTION# AGENCY# FACILITY ID# TANK ID# EI I I 10 10 11131 / 1 �21 V01014e 9-1 AGENCY FACILITY ID# APPROVED B NAME PHONE#WITH AREA CODE -71 zftg PERMIT APPROVAL DATE PER IT EXPIRATION DATE PERMIT AMOUNT SURCHARGE AMT. FEE CODE i IPT#FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIE r A FACILITY/SITEAPPLICATION, FORM'A',UNLESS AENT FORM`A' HAS BEEN FILED DATA PROCESSING COPY