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STATE OF CALIFQRNI " WATER RESOURCES CONTR OARD FORM 'B': UNDE GROUND STORAGE TANK PROAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EAC!♦TANK. MARK ONLY ❑ NEW PERMIT ��,.o .. Z ❑ 1 ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 10 ONE ITEM 2 INTERIM PERMIT 7 PERMANENTLY CLOSED TANK ❑4 AMENDED PERMIT ❑fi TEMPORARY TANK CLOSURE FACILITY/SITE NAME WHERE TANK IS INSTALLED: ❑8 TANK REMOVED (:JZI " NO L TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-$O SPECIFY FARM TANK-Y A. OWNERS TANK ID# '� W I.l B. MANUFACTURED BY: 7 C. YEAR INSTALLED l/ D. TANK CAPACITY IN GALLONS: cu 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A, 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B C. 1 UNLEADED [X2 LEADED E]3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL IlJ�� PRODUCT ❑4 GASAHOL E] 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARpOUS ❑ BO EMPTY ❑ g5 UNKNOWN ❑2 WASTE E] 7 METHANOL X,99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.If Pre-01 I- TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D CA S.#: A. TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER SYSTEM ❑ . UNKNOWN 2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT 99 OTHER NJSTEELPRON 2 STAIN ❑ LESS STEEL B.TANK 5 CONCRETE ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ ❑6 POLYVINYL CHLORIDE E] 7 ALUMINUM El I Opal METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZEDSTEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑q PHENOLIC LUNG LINING ❑5 GLASS LINING ❑6 UNLINED y ❑ IS LINING MATERIAL COMPATIBLE WITH 1 W%METHANOL? E]YES NO ❑❑ 99 OTHER WN D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT PROTECTION ❑5 CATHODIC PROTECTION ❑ 91 NONE 11 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATIO CLE A IF ABOVE GROUND, U IF UNDERGROUND,190TH IF APPLICABLE A.SYSTEM TYPE A U SUCTION A U 2 PRESSURE B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED RENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 91 NONE A U S UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYWNYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CON A U 9 GALVANIZED STEEL A U A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP KNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS S 6 PRECISION TESTING P S 7 RESSURE TESTING P S 91 NONE P S 95 UNKNOWN I. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE P s 99 OTHER 1. ESTIMATED DATE LA57 USED O/YR} 2. ESTfMATED QUANTITY OF SUBSTANCE REMAINING IN P�1 3. WAS TANK FILLED WITH v GALLONS INERT MATEMAL? YES ❑ NO THIS FORM HAS BEEN COMPLETED 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# TANK ID# CURRENT LOCAL A NCY FACILITY Ip k APPROVEp 6Y:NAME PHONE N WITH AREA CODE PERMIT NUMBER CC"lO Ql� PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE IIE CEI PT#r SSS/ BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED A FACILITY/SITE APPLICATION, FORM `A',UNLESS A CUARENT FORMA' HAS BEEN FILED DATA PROCESSING cnnv