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WATER RESOURCES CONTR OARD STATE OF CALIFORNIf UNDE GROUND STORAGE TANK PRO%AM FORM B . TANK PERMIT APPLICATION INFORMATIONZ TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING I FORMATION FOR EACH TANK. I�> ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED 1 NEW PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED w MARK ONLY ❑ ❑q AMENDED PERMIT ONE ITEM ❑ 2 INTERIM PERMIT STALLED: FARM TANK-YES❑ NO IV DO FACILITY/SITE NAME WHERE TANK IS INW W I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECWY A. NERS TANK ID MANUFACTURED BY: OW # a D. TANK CAPACIT'IN GALLONS: C.YEAR INSTALLED 11. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(AA),IS NOT MARKED,COMPLETE ITEM D. ❑ 3 DIESEL B C. ❑1 UNLEADED 2 LEADED A. 1 MOTOR VEHICLE FUEL E]2 PETROLEUM 1 PRODUCT E] 4 GASAHOL E] 5 JET FUEL E]6 AVIATION GAS V ❑3 CHEMICAL PRODUCT ❑ 4 OIL 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ D. IF NOT MOTOR HAZARDOUS SUBSTIANCE STORED&C.A.B.#CLE FUEL,ENTER NAME OF C.A.S.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D 95 UNKNOWN 1W IEWAUED ❑3 SINGLE WALLED WITH EXTERIOR UNEA E]A.TYPE OF / ❑99 OTHER SYSTEM SINGLE WALLED ❑4 BECONOAR4 CAMAINMENT STEEUIRON s ❑2 STAINLESS STEEL ❑3 RBERGIASS ❑4 STEEL CLAD WIF19ERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑ fi POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B 1W%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ I RUBBER LINE) ❑2 ALKYD LINING ❑3EPDXY LINING 4 PHENOLIC NKNOWNNING C.INTERIOR F-15 GLASS LINING ❑6 UNLINED LINING ❑IS LINING MATERIAL COMPATIBLE WITH Ion METHANOL? ❑YES ❑NO ❑99 OTHER ❑2TAA OR ASPHALT ❑3W WRAP ❑4 FIBERGLASS REINFORCED PLASTIC D. CORROSION ❑ I POLYETHLENEWRAP ❑99 OTHER PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,IBOTH IF APPLICABLENONE A U 5 UNKNOWN A U 99 OTHER ETE YVIW TYPE A POL U 1 SUCTION A U 2 PRESSURE 95 UNKNOWN A U 99 OTHER RPOL UCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TREAU 91 NONEA U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3STEEL CLAINYLDW/OFRP E(PVC) A U S 100%METHANOL COMPAUIBL�E RRNE IAL A U 5 ALUMINUM A 6 POLYV CONCRETE A U 9 GALVANIZED STEEL 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. WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND=WATER WELLS P 5 1 VISUAL CHECK P S 21NVENTORY RECONCILIATION P S y1 NONE P S 95 UNKNOWN P 8 99 OTHER P S 6 PRECISION TESTING P S 7 PRESSURE TESTING VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLED WITH 2.ESTIMATED QUANTITY OF INERT MATERIAL? YES NO A. ESTIMATED DATE LAST USED(MO/YR) SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY onTE KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED S SIGNATURE) LOCAL AGENCY USE ONLY FACILITY ID X TANK ID It # COUNTY JURISDICTION# AOENCY X [� oda o H r,, DN RRENT GENCY FACILITY APPROVED BY NAME PHONE N WITH AREA CODE /j 7 CU 0-� PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PERMIT NUMBER \/ FEE CODE ECEIPTN BY: CHECKN PERMIT AMOUNT SURCHARGE AML I THIS FORM MUST BE ACCOMPANIED BY A FACILITYTION, FORCOP'A',UNLESS A CURRENT FORMA' HAS BEEN FILED FORM B(6-29-e8) DATA PRO