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STATE OF CALIFORNI WATER RESOURCES CONTR OARD �sE FORM B'• UNDErGR • OUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK -YES ❑ NO ®--� I. TANK DESCRIPTION COMPLETE ALL ITFMS - IF IINI[NAWN — an CDF!`ICV A. OWNERS TANK ID # B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF LA.11- IS MARKED- COMPLFTF ITEM C IF !A 11 IS NAT uAIaVVn rnuol eTe 1Teu n A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B.TD ❑ 1 UNLEADED E]2 LEADED ❑ 3 DIESEL F-]3 CHEMICAL PRODUCT F-14 OIL ❑ 1 PRODUCT❑ 4 GASAHOL [:]5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS 1:180 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF HAZARDOUS SUBSTANCE STORED & C.A.S. # X114 C.A.S. #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, 8,C, & D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER B. CONSTRUCTION F—]1 STEEL/IRON ❑ 2 STAINLESS STEEL F—]3 FIBERGLASS F—]4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL F-]5 CONCRETE ❑ 6 POLYVINYL CHLORIDE F-]7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FRP U 1 STEEL/IRON ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR F-11 RUBBER LINED ❑ 2 ALKYD LINING El3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINED 8 100% METHANOL COMPATIBLE FRP ❑ 95 UNKNOWN A ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCI F A IF AROVF (-.Pni INFI u IF I INf1FR(-pni mr) RATH IF ADDI IL`A9kI F A. SYSTEM TYPE A U 1 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 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER SURCHARGE AMT. 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 U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY OR S FOR RFr.nNIlARY A PRIYARV I FAK nFTFCTIAN CVCTFu ul ICT oo /^jof l en P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH /' N � SUBSTANCE REMAINING IN GALLONS I INERT MATERIAL? [:]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 ANLY COUNTY # JURISDICTION # AGENCY # FACILITY ID # lf6 17 1 TANK ID # 101 (1 OL -4 CURRENT LOCAL AGENCY FACILITY ID # s APPROVED BY NAM PHONE # WITH AREA CODE PERMIT NUMBMR PERMIT APPROVAL DA PERMIT EXPIRATION DATE CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT # BY; ORM B (6-29-88) THIS FORM MUST BE ACCOMPANlMYA FACILITY/SITE APPLICATION, FORM `A', UNLESS .. RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY 1 00 W