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ATE OF CALIFOROi4 WATER RESOURCES - _ FORM `B': CON L BOARD UNDERGROUND STORAGE TANK PROGRAM TANK TAN s K PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY El NEW PERMIT L ONE ITEM ❑ E]3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION c9 I a. 2 INTERIM PERMIT ❑4 AMENDED PERMIT 7 ERMANENTLY CLOSED TANK FACILITY/SITE NAME WHERE TANK IS INSTALLED: ❑6 TEMPORARY TANK CLOSURE � 8TANK REMOVED �7 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—O SPECIFY C c FARM TANK-YES❑ NO A. OWNERS TANK ID# C. YEAR INSTALLED B. MANUFACTURED BY: D. TANK CAPACITY IN GALLONS: Z�O II. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B ❑3 CHEMICAL PRODUCT 1 UNLEADED ❑2 LEADED ❑4 OIL 03 DIESEL ❑5 HAZARDOUS 13-T--PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑80 EMPTY �95 UNKNOWN D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF ❑2 WASTE El METHANOL 1:199 OTHER(DESCRIBE IN ITEM D,BELOW) HAZARDOUS SUBSTANCE STORED&C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY BOX A,B,C,&D C.A.S.#: , l q A. TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER SYSTEM �2 SINGLE WALLED ❑95 UNKNOWN 4 SECONDARY CONTAINMENT ❑99 OTHER B.TANK RI ' STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑5 CONCRETE 116 POLYVINYL CHLORIDE 7 ALUMINUM ❑9 BRONZE El El8 100%METHANOL COMPATIBLE FRP 10 GALVANIZED STEEL 0 95 UNKNOWN ❑99 OTHER C. INTERIOR ElI RUBBER LINED ❑2 ALKYD LINING LINING El GLASS LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING 6UNLINED ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES❑ NO 2199 OTHER L � ❑95 UNKNOWN❑ D.CORROSION � i POLYETHLENE WRAP �2 TAR OR ASPHALT PROTECTION ❑5 CATHODIC PROTECTION El VINYL WRAP 4- REINFORCED—REINFORCED PLASTIC ❑91 NONE �95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE 1 SUCTION GLE WALLED A U 2 PRESSURE A U 3 GRAVITY B. CONSTRUCTION A 1 SIN 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 9 GALVANIZED STEEL A U)95 UNKNOWN A U 8 100%METHANOL COMPATIBLE FRP A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST B WA) P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING CIRCLED. P S 6 PRECISION TESTING P S 7 PRESSURE TESTING 1 NONE P S 95 UNKNOWN VI. INFORMATION ON TANK PERMANENTLY CLOSEDIN PLACE P S 99 OTHER 1. ESTIMATED DATE LAST USED(MO/YR) �2� ESTIMATED QUANTITY OF T CE REMAINING IN 3. WAS TANK FILLED WITH GALLONS 0 MATERIAL? ❑YES NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# 1:iEjFACILITY ID# TANK ID.( PERMIT NUMBER # CURRENT LOCAL AGENCY FACILITY ID# � V E � v APPW BY NAME1. � PHONE#WITH AREA CODE PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIENBY A FAMIAPPLICATION, FORM `A',UNLESS A MRENImFORMT HAS BEEN FILED A PROCESSING COPY