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S'a++niii'�E STATS OF CALIFRN WATER RESOURCES CONTR OARD RAGE TANK PRQSAM u �_ FORM `B'; UND GROUND STO = ® TANK PERMIT APPLICATION INFORMATION TANS COMPLETE A SEPARATE FOAM WITH THE FOLLOWINJI91 INFORMATION FOR EACH TANK. MARK ONLY F-1 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM El INTERIM PERMIT ❑4 AMENDED PERMIT a 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED qjoC] FARM TANK-YES❑ NO ❑ FACILITY/SITE NAME WHERE TANK IS INSTALLED: f 0 {�1�. l L TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY Lo B. MANUFACTURED BY: A. OWNERS TANK ID# D. TANK CAPACITY IN GALLONS: g(l C. YEAR INSTALLED II. TANK CONTENTS IF(AA),IS MARKED,COMPLETE ITEM C.IF(A.7),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL F-12 PETROLEUM B C. L] I UNLEADED [:] 2 LEADED ❑3 DIESEL 3 CHEMICAL PRODUCT 4 OIL ❑ 1 PRODUCT ❑ 4 GASAHOL E] 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ B0 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.It: HAZARDOUS SUBSTANCE STORED&C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑2 51NGLEWALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEELI IRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM El S 100%METHANOLCOMPATIBLEFRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPOY LINING ❑4 PHENOLIC LINING C. INTERIOR ❑6 UNLINED ❑95 UNKNOWN LINING ❑ 5 GLASSIINING ❑ ISUNINGMATERIAL COMPATIBLE WITH 1W%METHANOL? ❑YES ❑ NO ❑'99 OTHER ❑ 1 POLYENLENE WRAP F-] 2 TAR OR ASPHALT ❑ 3 VINYLWRAP [:] 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION PROTECTION F-15 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 I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U i 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 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE METHANOL COMUIBLE RP91 NE 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 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED, P S f VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P g 5 GROUNDWATER MONITORING WELLS P S fi PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.wAsrANKFILLEDWITH 1. ESTIMATED DATE LAST USED(MO/YR) 2- ESTIMATED QUANTITY OF INERT MATERIAL? =YES SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT. DATE APPLICANT'S NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY FACILITY ID# TANK IO# COUNTY# JURISDICTION# AGENCY# APPROVED BY NAME PHONE#WITH AREA CODE CURRENT LOCAL AGENCY FACILITY ID#IriR K 2-31/0 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE FEE CODE RECEIPT M BY: _ f } CHECK# PERMIT AMOUNT SURCHARGE AMT. (�/�/�yF/- ``W,'L� FORM B{6-29-Ba) THIS FORM MUST BE ACCOMPANIL A FACILITY/SOATAPPROCE, ORM'AY''UNLESS RENT FORM'A' HAS BEEN FILED