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STATE OF CALIFORN WATER RESOURCES CONTROARD i a. cY1. FORM `B': UND GROUND STORAGE TANK PR TANK PERMIT APPLICATION INFORMATIONtq4 Ftp r TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY E 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED f Tl PEj�y ,� AdA�ffi!." FARM TANK-YES❑ NO ❑ FACILITY/SITE NAME WHERE TANK IS INSTALLED: � r I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY B. MANUFACTURED BY: IPo A. OWNERS TANK ID# AST ~ TANK CAPACITY IN GALLONS: QL C. YEAR INSTALLED D. II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED, OMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL V PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ [:] 2 WASTE E] 7 METHANOL ❑ 99 OTHER(DESCRIBE 7N ITEM D,BELOW) 5 HAZARDOUS F-1 80 EMPTY [:] 95 UNKNOWN D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.W HAZARDOUS SUEISTANCE STORED&G.A.S.9 III. TANK CONSTR TION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF I DOUBLE WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEELIIRON ❑2 STAINLESS STEEL 3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 IN%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 BEER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR 5 GLASS LINING ❑6 UNLINED I v UNKNOWN E] / LINING IS LINING MATERIAL COMPATIBLE WITH 1 Q9%METHANOL? ❑YES E] NO 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑3 VINYL WRAP 4/fBERGLASS REINFORCED P STIC K PROTECTION ❑5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN �L- 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 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 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 B 14096 METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER /VV. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. p 5 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WRIER MONITORING WELLS P S 6 PRECISIONTESTING P S 7 PRESSURE TESTING 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 T37: AS TANK FILLED WITH SUBSTANCE REMAINING IN ERT MATERIAL? 0ES ❑ NO GALLONS THIS FORM HAS BEEN COMPUTED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TTANNK ID## o F-To-I o 116 1 To I CURRENT LOCAL_GENACY'FACILITY ID# APPROVED BY NAME PHONE#WITH AREA COD E PERMIT NUMBER f W PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-ee) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SOI ASA PCR CETION, OR pp CU UNLESS A RRENT FORMA' HAS BEEN FILED