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STATE OF CALIFORN WATER RESOURCES CONT BOARD FORM 'B': UND GROUND STORAGE TANK PRRAM TANK TANK PERMIT APPLICATION INFORMATION ` COMPLETE A SEPARATE FORM WITH THE FOLLOWING I ORMATION FOR EACH TANK. _m MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE 'TANK REMRMANENTLY OVED7 PERMANENTLY CLANK FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO ET I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# 1 B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY INGALLDNS: � 11. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF IRA),IS NOT MARKED,COMPLETE ITEM D. W A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM g, O_ 00 ❑ 1 UNLEADED ❑2 LEADED 3 DIESEL W' ❑3 CHEMICAL PRODUCT ❑q OIL 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS blilt ❑5 HAZARDOUS ❑80 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑7 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.#: ><111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D FPE OF ❑ UBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UN ER ❑95 UNKNOWN STEM 2 SI LE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER I STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑q STEEL CLAD W/FIBEfiGLASS REINFORCED PLASTIC NK ❑ 5 CONCRETETERIAL ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑S 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN E]99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING 3 EPDXY LINING ❑4 OUC LINING LINING ❑5 GLASS LINING ❑6 UNUNED 95 UNKNOWN ❑ISLINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENEWRAP ❑2 TAR OR ASPHALT 3 V LWRAP ❑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 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH U 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRONA U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A CONCRETE A U 7 STEEL CLAD W/FRP A U 9 GALVANIZED STEEL U 5 UNKNOWN A U B 100%METHANOL COMPATIBLE FRP A U 99 OTHER V. L K DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. oII S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS 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 SUBSTANCE REMAINING IN 3, WAS TANK FILLED WITH GALLONS INERT MATERIAL? ❑YES ❑ 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 S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# 3 9 TANK ID# CURRENT LOCAL AGENC]'FACILITY ID#e�e /� APPROVED BY NAME JcZ PHONE If WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTa BY FORMB(3-7-88) THIS FORM MUST BE ACCOMPA BY A FACILITYNITE APPLICATION, FORM 'A',UNLES ,URRENT FORM'A' HASBEENFILED A �,y� DATA PROCESSING COPY / '� 7' "