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STATE OF CALIFORNIO WATER RESOURCES CONTRO&ARD ..:.,�•�W: FORM `B': UNDERGROUND STORAGE TANK PRO RAM TANK TANK PERMIT APPLICATION INFORM COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. I O 1 NEW PERMIT ❑3 RENEWALPERMIT ❑5 CHANGE OFINFORMATION ❑7 P ANENTLY CLOSED TANK MARK ONLY ❑ ❑6 TEMPORARY TANK CLOSURE TANK REMOVED ( ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT cn .�(• � FARM TANK NO FV FACILITY/SITE NAME WHERE TANK IS INF.► I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SCIFY BE MANUFACTURED BY: A. OWNERS TANK ID# D. TANK CAPACITY IN GALLONS: EEE]]E1 C. YEAR INSTALLED II. TANK C NTENTS IF(A-1),IS MARKED,COMPLETE ITEM C.IF(A.1),ISNOT MCRKE❑D COMPLETE ITEM D. le LEADED ❑ 3 DIESEL A 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM s. PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑3CHEMICAL PRODUCT ❑ 401L 7METHANOL 99 OTHER(DESCRIBE IN ITEM D.BELOW) ❑5 HAZARDOUS ❑ 80 EMPTY [:] 95 UNKNOWN ❑ 2 WASTE ❑ ❑ 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: HAZARDOUS SUBSTANCE STORED&C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,h D A.TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLEWALLEOWITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM �SIN LEWAUED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ 0 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑1 RUBBER UNED ❑LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING UNLINED [a 95 KNOWN �L LINING ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES 0 N L'.�'""THER�y�'S'' D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION1 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A i SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TflENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL 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 U S 109%METHANOL COMPATIBLE FRP A IUD 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 8 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P DOSE WELLS P S 4 ELECTRONIC MONITOR P 6 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NO P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLED WITH 1. ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF INERT MATERIAL? []YES ❑ NO Np SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. DATE APPLICANT'S NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY FACILITY ID# TANK ID# E22 RISDICTION k AGE�� a- 3 o0 0 / APPROVED BY NAME PHONE N WITH AREA CODE CILITY IDN � (� PERMIT APPROVAL DATE FERMI EXPIRATION DATE T AMOUNT SURCHARGE AMT. FEE CODE RECEIPTN BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE TAPPR TION, ORM' ',UNLES A CURRENT FORMA' HAS BEEN FILED