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STATE OF CALIFORNI& WATER RESOURCES CONTR*OARD °\ FORM 'B': UND GROUND STORAGE TANK PROGRAM ` TANK TANK PERMIT APPLICATION INFORMATION a COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - s MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ` ❑ ❑ ❑ ONE ITEM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: .3 C FARM TANK-YES NO ❑ C.TT IV I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY J i A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. C l MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED DIESEL F-] 3 CHEMICAL PRODUCT E] 4 OIL MA-PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL [:] 6 AVIATION GAS El5 HAZARDOUS E] 80 EMPTY ❑ 95 UNKNOWN E] 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&CAS.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEDURON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑81W%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR 711 RUBBER LINED F-12 ALKYD LINING F--] 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑ 6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%MEfHANOL9 ❑ YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL 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 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 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 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE 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 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 1VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSEWELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P 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 SUBSTANCE REMAINING IN GALLONS INERT MATERIAL' ❑YES E] 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# UE = = 1 1 � 0 2. CU ENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE N WITH AREA CODE V PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE -31 CNECKN PERMITAMOUNT SURCHARGE AMT. FEE CODE RECEIPTN BY: FORM B(6-29-BS) THIS FORM MUST BE ACCOM D BY A FACILITYISRE APPLICATION, FORM 'A',UNL ,- CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY