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STATE OF CALIFORNIt& WATER RESOURCES CONTROSPARD „ : FORM `B': UNDE ROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH TH�FOLLOWI ORMATION FOR EACH TANK. zMARK ONLY 1 NEW PERMIT ❑3 RENEWAL PERMIT E OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT 4 AMENDED PERMIT ❑6TEMPORARY TANK CLOSURE 0 TANK REMOVED O W FARM TANK -YES NO DO FACILITY/SITE NAME WHERE TANK IS INSTALLED:316; (n I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY �( B. MANUFACT RED BY: A. OWNERS TANK ID# D. TANK CAP ITY IN GALLONS: B0� C.YEAR INSTALLED IWO 11. TANK!!! ONTENTS IF(AA),IS MARKED,COMPLETE ITEM C.IF(AA),IS NOT MA KED,COMPLETE ITEM D. A. ❑ ICLE FUEL ❑2 PETROLEUM B C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL �, / 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 8 AVIATION GAS ❑ PRODUCT L IA OIL ❑ S ❑BO EMPTY ❑95 UNKNOWN WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: HAZARDOUS SUBSTANCE STORED&C.A.S.# Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,S D 1 DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN A.TYPE OF F-1 ❑ SYSTEM F-12 SINGLE WALLED ❑4 SECONDSECONDARYCDNTAINMCONTAINMENT99 OTHER ❑ 1 STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ 0100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑�ALKYD LINING EPDXY LINING 4 PHENOLIC LINING C.INTERIOR 95 UNKNOWN LINING ❑5 GLASS LINING ❑ UNLINED❑IS UNING MATERIAL COMPATIBLEW100%METHANDL? 0:YES ❑ NO 99 OTHER ❑ 1 POLYETHLENEF-1WRAP ❑2TAR OR ASPHALT 3 VINYLWRAP 4 FIBERGLASS REINFORCED PLAST D.CORROSION IC PROTECTION F-15 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVIT(I 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 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESSISTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD WEEP A U 8100%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. P S 1 VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS it P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLED WITH 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF INERT MATERIAL? DYES ❑ NO SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. DATE APPLICANT'S NAME(POINTED&SIGNATURE) LOCAL AGENCY USE ONLY COUNTY# JURISDICTION � AGE FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FACILITY ID# APPROVED PHONE#WITH AREA CODE BY NAME f�E2z5 PERMIT NUMBER PERMIT APPROVALDATE PERMIT EXPIRATION DATE FEECODE RED # BY: CNECKM PERMIT AMOUNT SURCHARGE AMT. � l FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SA AAPPROCION, NORM 'COPY ',UNLESS A CURRENT FORMA' HAS BEEN FILED O