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STATE OF CALIFORNA WATER RESOURCES CONTBOARD FORM `B'; ,5 •°.,.; M<� UND GROUND STORAGE TANK PR RAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. F_R_NR MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ONE ITEM El PERMANENTLY CL ANK TERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED D' FACILITYISITE NAME WHERE TANK IS INSTALLED: 4—if J, FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# if Ip B. MANUFACTURFE BY: C. YEAR INSTALLED16 1 D, TANK CAPACITY IN GALLONS, O 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. I 4�-'b A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ) ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL � ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL P77-1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS Q ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 NKNOWN ❑ 2 WASTE El METHANOL [-] 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: xlll. TANK CONSTRUCTION MARK ON ITEM ONLY IN BOX A,B.C,&D A. TYPE OF O 1�1CUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM �f^s(/2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER B.TANK I STEEL/IRON ❑2 STAINLESSSTEEL ❑3 FIBERGLASS ❑ 4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑B 1"METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ IQ GALVANIZLDSTEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR 1 RUBBER LINED ❑2 ALKYD LINING 3 EPDXY LINING F-14 PHENOLIC LINING ❑ LINING ❑ 5 GLASS LINING ❑L 6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLFNE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ss 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 �OTHER AU 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FAP A U 8 100%METHANOL COMPATIBLE FAP A U 9 GALVANIZED STEEL A U 5 UNKNOWN A U 99 OTHER . LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 5 P VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS_ P S 6 PRECPSiON TESTIN P 5 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VL. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTI MAT DATE LAST USED(MO/YR) 2. ESTIMATE QUANTITY CF SUB T. MAINING IN 3 WAS A �F IAL?LFI)WITH I R MP(faL7 ❑YES ❑ NO GALLONS THIS—FOAM 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# ` _T_ � Fb D o ) I CURRENT LOCAL AGENCY ACILITY ID# AP R VE BY AME )-6—P �7 f� PHONE k WITH AREA CODE PERMIT NUMBER r l..• `� PE M A P..OVAL D E PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHA FEE CODE RECEIPT# BY: FORM B(3-7-6a) THIS FORM MUST BE ACCOMPANi r A FACILITY/SITE APPLICATION, FORM `A',UNLESS A RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY