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WATER RESOURCES CONTFIOARD STATE OF CALIFORN� FORM `B': UND GROUND STORAGE TANK PRM m .ti TANK PERMIT APPLICATION INFORMATION ,,p,.. Z TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 10 MARK ONLY ❑1 NEW PERMIT ❑3 RENEWAL PERMIT 7 CHANGE OF INFORMATION fBMANENTLY CLOSED TANK IT ❑6 TEMPORARY TANK CLOSURE B TANK REMOVED w ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDEDPERMFARM TANK.YES❑ NO IV 4. W FACILITY/SITE NAME WHERE TANK IS INSTALLED: tl/l F OD 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SFY B MANUFACTURED BY: MNIs1 A. OWNERS TANK IDD. TANK CAPACITY IN GALLONS: rJ �fl C.YEAR INSTALLED 11. (A.1),IS MARKED,COMPLETE ITEM C.IF(A 1),ISNOT MARKED,COMPLETE ITEM D TANK CONTENTS IF C. ❑3 DIESEL B ❑1 UNLEADED 2 LEADED A. 1 MOTORVEHICLE FUEL F-12 PETROLEUM 1 PRODUCT ❑4 GABAHOL El JET FUEL E]6 AVIATION GAS ❑3 CHEMICAL PRODUCT ❑ 4 OIL 2 WASTE 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) F-15 HAZARDOUS E]80 EMPTY ❑95 UNKNOWN ❑ ❑ C.A.S.N: O VEHICLE HAZARDOUS SUBSTANCE STORED&C.A.S.NOF 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D ❑95 UNKNOWN 1 BLE WALLED ❑3 SINGLE WALLED WITH D(TERIOR LINED A TYPE OF [:]99 OTHER SYSTEM 2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC ❑1 CONCRETE ❑8100%METHANOL COMPATIBLE FRP B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 UMINUM MATERIAL ❑10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER ❑9 BRONZE ❑ ❑2 AIKYp UNING ❑3 EPDXY UNING �UNKNOWN HENOLIC NTNG 1 RUBBER UNEO C.INTERIOR ❑ 5 GLASS UNING ❑6 UNLINED LINING ❑IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION 1 POLYETHLENEWRAP 2 TAR OR ASPHALT 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC ❑ V9,15 UNKNOWN [—]99 OTHER PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. 0 IF UNDERGROUND,BOTH IF APPLICABLE ONE A U 95 UNKNOWN A U 99 OTHER A.SYSTEM TYPE U 7 SUCTION A U 2 PRESSURE A U 3 GRAVITY B.CONSTRUCTION 1 SINGLE WALLED A 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 STAINLESSSTEEL A U 3 STEELICLAL CHLORIDE(PVC) A U 4 FIBE6METHANOL COMPAu1BLE FRpNE C. MATERIAL A U 5 ALUMINUM ASU -8 CONCRETE A U 9 GALVANIZED STEEL IV 95 UNKNOWN A U 99 OTHER OR S FOR SECONDARY,APRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY. P S 1 VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VAOOSE WELLS P 6 95EUN UNKNOWN MONITOR P S GROUNDWATER R MONITORING WELLS 99 OTHER 010)S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3 WAS TANK FILLED WITH 2.ESTIMATED QUANTITY OF INERT MATERIAL? ❑YES ❑NO 1.ESTIMATED DATE LAST USED(MONK) SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO�WTE DGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY TANK ID# FACILITY ID N COUNTY N JURISDICTION# AGENCY N � � Q 00 .2- 21ss APPROVED BY NAME PHONE M WITH AREA CODE CURRENT LOCAL AGENCY FACILITY ID M 4+# 17 AJ PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PERMIT NUMBER FEE CODE RECEIPT# BY: e CHECK# PERMIT AMOUNT SURCHARGE AMT. FORMB(6-29-88) THIS FORM MUST BE ACCOMPA BY A FACILITYISI TAPPROCESSINORM A',UNLESS URRENT FORMA' HAS BEEN FILED G COPY ..