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WATER RESOURCES CONTRO ARD CALIFORNI STATE (3F FORM `B': UNDE ROUND STORAGE TANI( PRO AM r , TAMC PERMIT APPLICATION INFORMATIONT TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK�RMANENTLY CLOSED TANK ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 1 NEW PERMIT ❑6 TANK REMOVED MARK ONLY 4 MENDED PERMIT ❑fi TEMPORARY TANK CLOSURE ONE ITEM 21NTERIMPERMIT FARM TANK—YES❑ NO � FACILITY/SITE NAME WHERE TANK IS INSTALLED: -- 1. SPECIFY TANK DESCRIPTION COMPLETE ALL ITEMS—l NKNOWN—SO ANUFACTURED BY: A. OWNERS TANK ID# D, TANK CAPACITY IN GALLONS: C. YEAR INSTALLED II. TS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D LEADED ❑3 DIESEL TA CONTEN B C. ❑ 1 UNLEADED A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM ❑ 1 PRODUCT ❑ 4 GASAHOL 5 JET FUEL ❑6 AVIATION GAS 3 CHEMICAL PRODUCT ❑ 4 OIL 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) ❑ 5 HAZARDOUS El 60 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ C.A.S.#: D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D ❑95 UNKNOWN ❑ i DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER A.TYPE OFE:]99 OTHER ❑2 4 SECONDARY CONTAINMENT SYSTEM SINGLE 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC 1 STEELI IRON ❑2 STAINLESS STEEL 3 FIBERGLASS 6 100%METHANOL COMPATIBLE FRP B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE 1 ALUMINUM ❑ MATERIAL ❑ 99 OTHER ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 2 ALKYD LINING ❑3 EPDXY LINING [:14 PHENOL1C LINING ❑ 1 RUBBER LINED ❑95 UNKNOWN C. INTERIOR ❑ 5 GLASS LINING 6 UNLINED 1111 LINING 99 OTHER ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANDL? YES ❑ NO ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP 4 FIBERGLA`S,S1 REINFORCED PLASTIC D. CORROSION ❑ 1 PCLYETHLENEWRAP 99 OTHER PROTECTION ❑ 0 CATHODIC PROTECTION ❑91 NONE El 95 UNKNOWN IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDDERIGROU NAD',BOTH IF ATY APPLICABNO E A U 95 UNKNOWN A U 99 OTHER A U 1 SUCTION A 2 PRESSURE A.SYSTEM TYPE DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED U U 4 FIBERGLASS FIFE A U 91 NONE A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PIG) U 1 D09b METHANOL COMPATIBLE FRP A U 6 CONCRETE A U 7 STEEL CLAD WIFRP okc—C. MATERIAL A U 5 ALUMINUM A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U gg OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDAR4,E PRI4NGAIRYIC MLGEA LEAK R SYSTEM MUST MTGBECIRCLED. WELLS p S 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLSt�5 95 UNKNOWN P S 99 OTHER p S t VISUAL GHECK P S 91 NONE P S 6 PREC9510N TESTING P S 7 FRESSUflE TESTING VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLED WITH 2. ESTIMATED QUANTITY OF INERT MATERIAL? ❑YES El NO 1. ESTIMATED DATE LAST USED(UO/YR) SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT.f AP LICANT`S NAME(PRINTF SIGNATURE} [,� '� O� LOCAL AGENCY USE ONLY FACILITY ID# TANK I7CODE JURISDICTION# AGENCY# E=E PHONE#WiTH AREA APPROVED NAME CURRENT LOCAL AGENCY FACILITY ID# PERMIT APPROVAL DATEPERMIT EXPIRATION DATE PERMIT NUMBER EIPT CHECK# PERMIT AMOUNT URCHARGE AMT. FEE CODE C FAGILITYP FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A DATA PROCESSING COPY'A',UNLESS A CURRENT FORM"A' HAS BEEN FILED