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STATE OF CALIFORNGROUND STORAGE TANK PWATER RESOURCES CONTR BOARD`°�> �y Eui Nf s FORM `B': UND R RAM TANK _ _ - - TANK PERMIT APPLICATION INFORMATION %,VIMrl-C 1 e A *CrAnA I C I'VF(IIII WI I M I nr- FVLLVWINU IN YHMATION FOR EACH TANK. �•a-�-,"o-eN%' MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION 1:17 P��ANK ANENTLY CLOSED TANK ONE ITEM F-]2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED:1 FARM TANK - YES ❑ NO TANK DESCRIPTION COMPLETE ALL ITEMS- IF UNKNOWN - SA SPECIFY A. OWNERS TANK ID # B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: i f11�1� v - - 1 v 1r IM. 1), 10 111Anacu, -.,umrLC 1 C 11 CM V. or (A.1), IS PIV 1 mAnRCU, GVMI'Lr 1 r 11 tM U. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. ❑ 1 BLE WALLED ❑ 1 UNLEADED 2LEADED 3 DIESEL F-]3 CHEMICAL PRODUCT 4 OIL 1 PRODUCT❑ 4 GASAHOL 5 JET FUEL 6 AVIATION GAS FEI ❑ 5 HAZARDOUS 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. # C.A.S. #: x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXA, B, C, & D f A. TYPE OF ❑ 1 BLE WALLED F-13 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 1 STEEL/IRON ❑ 2 STAINLESS STEEL F-13 FIBERGLASS r-14 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL F-]5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FRP C. MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A U 8 100% METHANOL COMPATIBLE FRP F-11 RUBBER LINED ❑ 2 ALKYD LINING F-]3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNLINEDKNOWN CHECK # PERMIT AMOUNT SURCHARGE AMT. ❑ IS LINING MATERIAL COMPATIBLE WITH i METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT F-13 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. Fil PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A &l 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 Ain)995 UNKNOWN A U 99 OTHER j APPROVED BY N!�Z-ff- 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 CLAD W/FRP A U 8 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A05 UNKNOWN A U 99 OTHER LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P1 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 S5 PRECISION TESTING S 7 PRESSURETESTING 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 FACILITY ID # SUBSTANCE REMAINING IN INERT MATERIAL? ElYES ❑ NO I I I 1 GALLONS i 6 lo I l Iv- lo I A 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 # AGENCY # FACILITY ID # TANK ID # HE I I I 1 0 1 1 6 lo I l Iv- lo I A Fo-c) -/] CURRENT LOCAL N Y FACILITY ID.1t j APPROVED BY N!�Z-ff- PHONE # WITH AREA CODE U S/ PERMIT NUMBER PERMIT APPROVAI,DATE PE IT EXPIRATION DATE 6V CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT # BY: FORM B (3-7-88) THIS FORM MUST BE ACCOMPANIE79Y A FACILITY/SITE APPLICATION, FORM 'A', UNLESS A WRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY W ., 4