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STATE OF CALIFORNIA9 WATER RESOURCES CONTROLARD go UNDERGROUND STORAGE TANK FROG A FORM B TANK PERMIT APPLICATION INFOR TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWIN INFORMATION FOR EACH TANK. 1 0 5 CHANGE OF INFORMATION ❑7 PERMANENTLY TANK 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑B TANK REMOVE / MARK ONLY ❑ ❑q AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE W ONE ITEM ❑2 INTERIM PERMIT FARM TANK-YES❑ NO W FACILITY/SITE NAME WHERE TANK IS INSTALLED: 8 _ AIN. I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY JRED BE MIFYURED BY: to A. OWNERS TANK ID# D. TANK CAPACITY IN GALLONS: OQ C.YEAR INSTALLEDD. II. TAN ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMEPALDE DE ITEM 2 LEADED 3 DIESEL C.B. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) ❑5 HAZARDOUS ❑BO EMPTY ❑95 UNKNOWN F-12 WASTE ❑ 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,A D E]95 UNKNOWN 1 UBLE WALLED ❑3 SINGLE WALLED WITH DRERIOA LINER A TYPE OF ❑ ❑q SECONDARY CONTAIN ❑99 OTHER SYSTEM 2SINGLE WALLED 2 STAINLESS STEEL F-] 3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC F-1 1 STEELIIRON 8100%METHANOL COMPATIBLE FAP S.TANK F-15 CONCRETE ❑6 POLYVINYLCHLORIOE ❑7 WMINUM ❑ MATERIAL ❑9 BRONZE E] 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYOUNING ❑3 EPDXY LINING ❑ HENOLIC LINING C. INTERIORUNKNOWN LINING ❑ 5 GLASS LINING ❑6 UNLINED ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? YES El NO 99 OTHER ❑ 1 POLYETHLENEWRAP ❑2TAR OR ASPHALT ❑ INYL WRAP E14 FIBERGLASS REINFORCED PLASTIC D. CORROSION 95 UNKNOWN ❑ 99 OTHER PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A 95 UNKNOWN A U 99 OTHER A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 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 S ALUMINUM A }7�6 CONCRETE A U 7 STEEL CLAD W/FRP A U 81 C. COMPATIBLE ERR A U 9 GALVANIZED STEEL A 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 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 3 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS )qL P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER 1(/VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3 WAS TANK FILLED WITH 2.ESTIMATED QUANTITY OF INERT MATERIAL? ❑YES ❑ NO 1. 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 KNOW TE DGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY TANK ID# FACILITY ID# COUNTY# JURISDICTION# AGENCY# 1 V' K ® APPROVED NAME PHONE M WITH AREA CODE CURRENT LOCAL AGENCY FACILITY ID# /1 y y G M PERMIT APPROVAL DATE// PERMIT OEXPIRATION DATE PERMIT NUMBER �LCGMECKM PERMIT AMOUNT SURCHARGE AMT. FEE CODE ECEIPT# BY: it1l /ylyyAgA 8(6-29-88) THIS FORM MUST BE ACCOMPANIED BY AFACILITYISREAPPLICATION, FORM'A',UNLESS A CURRENT FORMA' HASSEENFILED (�/X 1 DATA PROCESSING COPY