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STATE OF CALIFORNIP WATER RESOURCES CONTRO' 'OARD FORM 'B': UNDE I�{GROUND STORAGE TANK PROMAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT 5�115 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: .( 1/ FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I� A. OWNERS TANK ID# .S3 B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: W II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM 8. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT 04 OIL 's 1 PRODUCT ❑4 GASAHOL E:] 5 JET FUEL [:]6 AVIATION GAS 5 HAZARDOUS ❑80 EMPTY [:] 95 UNKNOWN 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF 1 HAZARDOUS SUBSTANCE STORED 8 C.A.S.# r Q(, ' C.A.S.#: .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,8 D A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM [5;J!SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER R ' STEELARON 2 STAINLESS STEEL F-� 3FIBERGLASS 4STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM B 100%METHANOLCOMPATIBLEFRP MATERIAL El 9 BRONZE ❑ 10 GALVANIZED STEEL E]95 UNKNOWN 99 OTHER C. INTERIOR F--j 1 MBBERUNED ❑2 ALKYD LINING ❑3 EPDXY UNING 4 PHENOLIC LINING LINING ❑5 GLASS LINING ®6 UNLINED ❑96 UNKNOWN ❑IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP Z2 TAR OR ASPHALT 3VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 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 I SUCTION A dD 2 PRESSURE A U 3 GRAVITY A U 99 OTHER S.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A gp 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE 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 A®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 8 1 VISUAL CHECK O8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 6 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS POS 6 PRECISION TESTING P 8 7 PRESSURE TESTING 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 GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? YES [-] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 10 o / 16 1 3 I 10 1Ci1 G 1 3 CURRENT LOCA APPROVED Ay ENCY EAC141TY 10# APPROVEEE�NAME ' PHONE#WITH AREA CODE PERMIT NUMBER I/'/ l/(/`I_ PERMIT APP110VAL DATE PERMITErCOWDATE CHECKN PERMITAMOUNTI SURCHARGEAMT. FEE CODE I AIECEIPT# BY: FORM B(3-7-66) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY IN