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STATE OF CALIFORNI WATER RESOURCES CONTRtOARD FORM B': LIND�WGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION ;. COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. •o MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT U216CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS o•„K ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT6 TEMPORARY TANK CLOSURE ❑ ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: O � FARM TANK-YES❑ NO ❑ 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN— SO SPECIFY (p A. OWNERS TANK ID# 0 8, MANUFACTURED BY C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: QOD II. TANK ONTENTS IF(At),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. (I(✓� A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. FE: 1 UNLEADED �77 LEADED ❑3 DIESEL❑3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT 4 GASAHOL JET FUEL ❑6 AVIATION GAS❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN 2 WASTE 7 METHANOL ❑ 9 OTHER(DESCRIBEIN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED& CAI. All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,d D AL TYPE OF ❑ I UBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARYGONTAINMENT ❑99 OTHER STEBUIRON ❑25'TAINLESSSTEEL ❑ 3FIBERGLASS [:] 4STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.MATE1RIAL ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8100%METHANOLCOMPATIBLEFRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER F—] I RUBBER LINED ❑ LKYOUNING ❑ 3 EPDXY LINING ❑ C. INTERIOR 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ISUNING MATERIAL COMPATIBLE WITH 10096 METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENEWRAP ❑2 TARORASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 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 99 OTHER B.CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH 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 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 0 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. PILL P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS 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 1. ESTIMATE DTE LAST USED(MO/YR) 2 EST)MATED QUANTITY OF 3. WAS TA K FILLED WITH S S NCE REMAINING IN R AT IAL? ❑YES ❑ NO GALLONS THIS FO M HAS BEEN COMPLETED UNDER PENAL OF PERJURY,AND TO THE BEST OF MY KNOWLE GE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 3 10101 1 Z I D O O I CURRENT LOCAL AGENCY FACILITY 10# AP VE BY NANF.ff PHONE#WITH AREA CODE 610 o(� W PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: �LLV FORM B(3-7-B8) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY