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TATE OF CALIFORN WATER RESOURCES CONTROL BOARD D STORAGE TANK II AGRAM a �a FORM B : UN GROUN TANK TANK PERMIT APPLICATION INFORMATION �. a COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK_ MARK ONLY ❑ -9lf aPNP 1 NEW PERMIT F-13 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑� 7 PERMANENTLY CLOSE0.TAA11 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED ONE ITEM El INTERIM PERMIT El AMENDED PERMIT ❑ M TANKYES❑ NO FACILITY/SITE NAME WHERE TANK 1S INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: ©o 00 11. TANK LATENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE IT D B C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL 00 A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM F-13 CHEMICAL PRODUCT F-] 4 OIL /, PRODUCT [j 4 GASAHOL ❑ 5 JET FULL ❑ 6 AVIATION GAS 95 UNKNOWN 2 WASTE El METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) ❑ 5 HAZARDOUS F-180 EMPTY ❑ D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.0: HAZARDOUS SUBSTANCE STORED&C.A-S.# x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 UBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER E]95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT E]99 OTHER 1 STEELIIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W41BERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLOHIOE ❑7 ALUMINUM ❑ 6 100%METHANOL COMPATIBLE FRP MATERIAL �y 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER C. INTERIOR L❑J 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING UNKNOWNINING LINING ❑ 5 GLASS LINING ❑6 UNLINED ❑ IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? ❑YES ❑NO ❑ 99 OTHER O. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALTV95 INYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE u 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION ;-U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 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 U B 100%METHANQ COMPATIBLE FRP C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD WIFRP A A U 9 GALVANIZED STEEL U 5 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. DS I 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 6 PRECISION TESTING P 5 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER Vl. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3 WAS TANK FILLED WITH 1. ESTIMATED DATE LAST USED(MOIYR) 2. ESTIMATED QUANTITY OF INERT MATERIAL? YES ❑ NO SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&StGNATURE) LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# V CURRENT LOCAL AGENCY FACIL�ITY ID# APPROVED BY NAME PHONE#WITH AREA CODE -7-0 1 f PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PERMIT NUMBER FEE CODE RECEIPT# BY: CHECK# PERMIT AMOUNT SURCHARGE AMT. \\� FORM `A',UNLESS RRENT FORM'A' HAS BEEN FILED �7 V FORM B(s-7-e®Y THIS FORM MUST BE ACCOMP _D BY A FAGiLITY1SDIATAAPPPLROCESSING COPY