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STATE OF CALIFORMWATER RESOURCES CONTE BOARD FORM 'B': UNDT iGROUND STORAGE TANK PR�RAM 4 TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ❑ 7 PERMANENTLY CLOS TANK MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ' TANK REMOVED 0 ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE - I ' �� FARM TANK-YES NO z FACILITY/SITE NAME WHERE TANK IS INSTALLED: N 1 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK 10# I B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 37j--0 CA) II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM CT2WASTE IF(A.1) IS NOT MARKED,COMPLETE ITEM D. Lrl A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM O ❑ 1 UNLEADED ❑ 2 LEADED DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL T ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑ SO EMPTY ❑ 95 UNKNOWN ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: HAZARDOUS SUBSTANCE STORED&C.A.S.# All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A TYPE OF MAUBLE WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER F-1 95 UNKNOWN SYSTEM ,F?{2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER I STEEL/IRON ❑ 2 STAINLESSSTEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 1M%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 AUKYD LINING F-13 EPDXY LINING ❑ 4 PHENOUC LINING C. INTERIOR F-1 5 GLASS LINING 6 UNLINED F-195 UNKNOWN - LINING F-1 ISURING MATERIAL COMPATIBLE NTH 100%METHANOL? DYES ❑ NO F-1 99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑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(U,)Il 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 FIBERGLASS PIPE C.MATERIAL A U 5 ALUMINUM A6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 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 S 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE LASTU ED(MO/YR) 2. ESTIMATE QUANTITY OF 3. WAST KFILLEDWITH GALNS SUBSTAN EMAINING IN I R ERIALP ❑YES ❑ NO LO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OP 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# lol 61 1 6 1 131 1 do 10 CURRENT LOCAL AGENCY FACILITY ID# APPR ED BY PHONE#WITH AREA CODE \ PERMIT NUMBER PERMIT APPROVAL DA ERMIT EXPIRATION DATE CHECKN PERMIT AMOUNT SURCHARGEAMT. FEE CODE _RECEIPT# BY: FORMB(3-7-66) THIS FORM MUST BEACCOMPAN YAFACILITY/SITE APPLICATION, FORM `A',UNLESSA \RENT FORMW HASBEENFILED DATA PROCESSING COPY