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STATE OF ICALIFORNI WATER RESOURCES CONTROARD FORM 'B': UNDERGROUND STORAGE TANK PRO AM Qp TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 1110 F-11 NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK MARK ONLY ONE ITEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE F-1 6 TANK REMOVED / WI FARM TANK-VES NO FACILITY/SITE NAME WHERE TANK IS INSTALLED: �o• I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN SOED. Y W NUFACTURED BY: A. OWNERS TANK ID 2/ C. YEAR INSTALLEDi� NK CAPACITY IN GALLONS: S(J II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,C PLETE ITEM D. B C. 1 UNLEADED ❑2 LEADED 3 DIESEL A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM ❑3 CHEMICAL PRODUCT 4 OIL PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. 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,8 D A TYPE OF tF-1 OUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM NGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER TEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK ONCRETE ❑6 POLYVINYLCHLORIDE ❑7 AL MINUM ❑ B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER UNED ❑2 ALKYO LINING �3 EPDXY LINING ❑4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑6 UNLINED ©'991!NKNOWN LINING ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES 0 NO OTHER � D. CORROSION ❑1 POLYETHLENE WRAP [DlTAROA ASPHALT ❑3 V LWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 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 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 11 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 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A %6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A(V95 UNKNOWN A U 99 OTHER VEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUALCHECK P 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P 8 6 ELECTRONIC MONITOR D 9 99GOROHFN�D WATER MONITORING WELLS 8 6 PRECISION TESTING S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TA KFILLED WITH 1. ESTIMATED DAT LAST USED(MO/YR) 2. SUsSTTIMTEDOU NTITVOFAN E LNG IN pALLONB IN A RIAL? []YES E] NO SUSST THIS FOR HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, RJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. DATE APPLICANT'S NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY PCHECK# UNTY# JURISDICTION# AGENCY# FPCILITYIDF# 77] 0 APPROVED BY NAM T LOCAL AGENCY FACILITY ID# �l e-:K8UMBER PERMIT APPROVAL DATE PERTION DATE PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT M BY: All FORM B(6-29-BB) THIS FORM MUST BE ACCOMPAN E BY A FACILITY/SA AAPPROCESSIFORo `A',UNLES URRENT FORMA O ' HAS BEEN FILED