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STATE OF CALIFORNIA WATER RESOURCES CONTROARD FORM B': UNDER ROUND STORAGE TANK PRO AM TANK PERMIT APPLICATION INFORMATION m COMPLETE A SEPARATE FORM WITH THE FOLLOWIN INFORMATION FOR EACH TANK. TANK G " 1 NEW PERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLO NK MARK ONLY ❑ IT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED q AMENDED PERM / ONE ITEM ❑21NTERIM PERMIT ❑ 6A FARM TANK-YES❑ NO W [W FACILITY/SITE NAME WHERE TANK IS INSTALLED: q 5T 5 IV,7 15-w SIP 00 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY BE IIFNUFACTURED 8Y: Y( 2 A. OWNERS TANK ID# O O D. TANK CAPACITY IN GALLONS: C. YEAR INSTALLED D II. TANK ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NO 7 MARKED, OMPLETE ITEM D. B C. 1 UNLEADED ❑2 LEADED ❑3 DIESEL 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 ❑ 60 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ ❑ D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.W HAZARDOUS SUBSTANCE STORED A C.A.S.# 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,&D A.TYPE OF ❑�OUBLE WALLED ❑3 SINGLE WALLED WITH FXIERIOR LINEfl ❑95 UNKNOWN fL"iJlf ❑4 SECONDARY CONTAINMEHF ❑99 OTHER SYSTEM 2 INGLEWALLED 1 STRUIRON ❑2 STAINLESS STEEL ❑3FIBERGLASS ❑ 4STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC ❑ 6 POLYVINYLCLORIDEEI7JUMINUM ❑B 100%METHANOL COMPATIBLE FAP B.TANK 5 CONCRETE � MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD UNING ❑3 EPDXY UNING neHENOUC LINING C. INTERIOR ❑ 5 GLASS LINING ❑6 UNLINED 95 UNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2TAR OR ASPHALT ❑3 VINYLWRAP ❑ 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 E A 95 UNKNOWN A U 99 OTHER A.SYSTEM TYPE A U 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 U 95 UNKNOWN A U 99 OTHER A U i STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 6 ALUMINUM A l�6 CONCRETE A U 7 STEELCLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP 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. 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P B 5 GROUNDWATER MONITORING WELLS O S 6 PRECISION TESTING P 5 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3 WAS TANK FILLED WITH 2. ESTIMATED OUANTIIY 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 KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY FACILITY ID# TANK ID# COUNTY# JURISDICTION# AGENCY# �E � � � � O NAPPROVED BY NAME PN INE k WITH AREA CODE CURRENT LOCAL AGENCY FACILITY PERMIT NUMBER V PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ECEIPT# BY: CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIED A FACILITY/SITE APPLICATION,P FORNG COPYA',UNLESS A4. RENT FORM'K HAS BEEN FILED O _J