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TE OF CALIFORN WATER RESOURCES CONTR�BOARDAGE TNK PROGRAM =` . STA FORM `B': UNDERGROUND PLICATIONANFORMAT ON TANK PERMIT AR COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION 10 TANK ION FOR EACH TANK 10 MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSE TA ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FARM TANK-YES❑ NO FACILITY/SITE NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY', C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: e�d� I1. TANK C LATENTS IF(A.1),15 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL ❑ 3 CHEMICAL PRODUCT 4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS E]95 UNKNOWN a 2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) F-1 5 HAZARDOUS El 80 EMPTY D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF CA S HAZARDOUS SUBSTANCE STORED&C.A.S.# 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A.TYPE OF ❑��21NCLEWALLED BLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 12 3 STEELIIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ T ALUMINUM ❑ 8 10096 METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RU98ER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4pi6OLIC LINING C. INTERIOR ❑ 5 GLASS LINING ❑6 UNLINED 95 UNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT VIUNY LWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION [:] 5 CATHODIC PROTECTION E:] 91 NONE KNOWN ❑ 99 OTHER IV. PIPING INFORMA ION CIRCLE A IF ABOVE GROUND, 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 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 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 W 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 6 100%METHANOL COMPATIBLE FRP 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. P 5 1 VISUAL CHECK S 2 INVENTORY RECONCILkAT10N P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELLS p 3 6 PRECVSIONTESTING P 3 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN A S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 2, ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH ESTIMATED DATE LAST USED(MOlYR) INERT MATERNAL? GALLONS F-1YES ONO SUBSTANCE REMAINING IN THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID If ® F I I In lo I/ 7,1 1/10 L-1 0 1 -L 0 0 g] APPROVED BY NAME PHONE#WITH AREA CODE CURRENT LOCAL AGENCY FACILITY D#[1 Je PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK k PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT k BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIEM A FACILITYISITE APPLICATION, FORM 'A'.UNLESSAL9WENT FORMA' HAS BEEN FILED DATA PROCESSING COPY