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STATE OFCALIFORNft WATER RESOURCES CONT ARD 5E FORM `B': UNDERGROUND STORAGE TANK PRO AMa TANKTANK PERMIT APPLICATION INFORMATION F '^" COMP TE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. b MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION F-] 7 PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT El 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 On A. OWNERS TANK ID# B. MANUFACTURED BY: mk- C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 0o C) II. TANK COTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. li A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C• 1 UNLEADED 2 LEADED DIESEL II 3 CHEMICAL PRODUCT �4 OIL 1PRODUCT 4 GASAHOL 5 JET FUEL 6 AVIATION GAS 5 HAZARDOUS 80 EMPTY �95 UNKNOWN 2 WASTE 1 7 METHANOL E] 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.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D i i A.TYPE OF ❑ 1 DO BLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN I SYSTEM 2 SINGLEWALLED 4 SECONDARY CONTAINMENT 99 OTHER STEEL/IRON 2 STAINLESS STEEL F-�3 FIBERGLASS F-] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM F-1 8 100%METHANOL COMPATIBLE FRP MATERIAL 0 9 BRONZE E] 10 GALVANIZED STEEL Ej 95 UNKNOWN 99 OTHER f j 1 RUBBER LINED 2 AL LINING 3 EPDXY LINING 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING UNLINED 95 UNKNOWN j ❑ ISLINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑ NO 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP OMPA R ASPHALT F-13 VINYL WRAP [:j4 FIBERGLASS REINFORCED PLASTIC PROTECTION [:j5 CATHODIC PROTECTION91 NONE 0 95 UNKNOWN E]99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A 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 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER �U STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE '4 C. MATERIAL A-ll 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. (o J 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 ;JS 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER I VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH j SUBSTANCE REMAINING IN INERT MATERIAL? YES NO 9 GALLONS i THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. j� APPLICANT'S NAME(PRINTED&SIGNATURE) DATE t LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# ® 0 1 7L Lo lo I v / l CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANI Y A FACILITY/SITE APPLICATION, FORM`A',UNLESS RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY