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STATE OF CALIFORNIA WATER RESOURCES CONTRO ARD DE ROUND STORAGE TANK PRO AM FORM `B': UN - z TANK PERMIT APPLICATION INFORMATION FOR 10 TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH0 7 PE ANENTLY C „ ❑3 RENEWAL PERMIT ❑5 CHANGEOFINFORMATION TANK REMOVED 1 NEW PERMIT ❑6 TEMPORARY TANK CLOSURE (JJ MARK ONLY ❑ 4 AMENDED PERMIT f"a ONE ITEM ❑2 INTERIM PERMIT FARMTANK-YES❑ NO FACILITY/SITE NAME WHERE TANK IS INSTALLED: Zb6 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY ANUFACTURED BY: A. OWNERS TANK ID# D. TANK CAPACITY IN GALLONS: dd C.YEAR INSTALLED T MARKED,COMPLETE ITEM D IF(A.1),IS MARKED,COMPLETE ITEM C.IF(p.1),I 2 LEADED 3 DIESEL 11. TANK NTENTS B c. 1 UNLEADED �6 AVIATION GAS A. 1 PRODUCT 7 METHANOL 1 MbTOR VEHICLE FUEL ❑2 PETROLEUM ❑4 GASOHOL ❑5 JET FUEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL L 99 OTHER(DESCRIBE IN ITEM D,BELOW) F-15 HAZARDOUS El 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ C.A.S.#: D HAZARDOUS MOTOR.VEHICLE STORED&O.A.B.#NAME OF 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&0 ❑95 UNKNOWN n 1�UBLEWALLED ❑3 SINGLE WALLED MTH DOERIOA UNER ❑OTHER A.TYPE M `- GLE WAS ❑4 SECONDARY COMAINMEM SYSTEM VuNN 3FIBERGLASS ❑4STEEL CSW/FIBERGLASS REINFORCED PLASTIC 1 STEEUIRON ❑2 POLYVIINYSTAINLSTEEL ❑ B.TANK ❑ 5 CONCRETE 8 POLYVINYLCHLORIDE T ALUMINUM ❑8 OTHERMETHANOL COMPATIBLE FRP 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER MATERIAL ❑y BRONZE ❑ ❑ ❑ ❑2 ALKYD LINING ❑3 EPDXY LINING iPHENOUC K KNOWN LINING 1 RUBBER UNEO meq' C. INTERIOR ❑5 GM LINING ❑6 UNUNED LJ LINING ER ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ED YES [I NO 990TH ❑3 WRAP E]4 FIBERGLASS REINFORCED PLASTICD. CORROSION ❑I pOLYETHLENEWRAP ❑2 TAR OR ASPHALT VIUNKNOWN ❑99 OTHER PROTECTION E]5 CATHODIC PROTECTION E]91 NONE IV, PIPING INFORM N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE E A u 95 UNKNOWN A U 99 OTHER A.SYSTEM TYPE A u sucTloN A U 2 PRESSURE A U 3 GRAVITY B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEpoLYD TRENCH A U 91 NO A U 4AFI FIBERGLASS PIPE N AAUU919 NONE E A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U B 100%METHANOL COMPATIBLE FRP A 6 CONCRETE A U 7 STEELCLADW/FRP C.MATERIAL A U 5 ALUMINUM A U gg OTHER A U 9 GALVANIZED STEEL A 5 UNKNOWN V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. LLS Is S 91 No P 8 95 UNKNOWN P S 99 OTHER 1 P 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 d ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WE ,N1 P S 6 PRECISION TESTING P S 7 PRESSURE TESTING VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANKF LLEDW H 2.ESTIMATED QUANTITY OF INERT MATERW.? YES MD 1.ESTIMATED DATE LAST USED(MO/ 8) SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST DF MY KNODATE DGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) �. LOCAL AGENCY USE ONLY FACILITY ID# z Ar+x 1D» COUNTY# rJURISDICTION# AGENCY# D V 8 / 3 PHONE N WITH AREA CODE APPROVED BY NAME CURRENT LOCAL AGENCY FACILITY ID# V PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE FEECODE RECEIPTN CNECK N PERMIT AMOUNT SURCHARGE AMT. �If FORM B(6-29-66) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE A PROCESSING ON, OCOP A',UNLESS A URflENT FORMA' HAS BEEN FILED