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STATE OF CALIFORNM WATER RESOURCES CONTR ARD FORM 'B': UND GROUND STORAGE TANK PR AM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. --_ z 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 P MANENTLY CLOSED TANK ONE ITEM F__] 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVED odf (A� FACILITYASITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO N I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY f.► WKID# d B. MANUFACTURED BY: CA) C. YEAR INSTALLEDD. TANK CAPACITY IN GALLONS: 0 I 9L II. TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTORVEHICLE FUEL ❑ 2 ETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL F-]3 CHEMICAL PRODUCT W4 OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ BO EMPTY ❑ 95 UNKNOWN g2 WASTE ❑ 7 METHANOL [;KOTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAMEOF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,&D A. TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER Zli-STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CUD WIFIBERGUSS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING F13 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING �UNUNED ❑� 95 UNKNOWN [-] IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO IJyN OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TAA OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 RBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION J�91 NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION U 1 SINGLEWALLED A U 2 DOUBLEWALLED 3 LINEDTRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U i STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL AALUMINUM A U B CONCRETE A U 7 STEEL CLAD W/FRP A U 6100%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 SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 / VISUAL CHECK P S 2 INVENTORY RECONCILIATION 8 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED D TE LAST USED(MO/YR) 2.ESTIMATE QUANTITY OF 3.WAA TANK FILLED WITH SUBSTA WEMAINING IN GALLONS /041 MATERIAL? [:]YES ❑ NO THIS FOhM HAS BEEN COMPLETED UNDER PENALTY bF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# a] 1 a 10 1 / I8 � I ol I-� I C) Ii CURRENT LOCAL AGENCY EACILITY ID# APPRp ED BY NAME PHONE M WITH AREA CODE 6 lz PERMIT NUMBER PERMIT APPROVAL DATE PERMIT E1LP1 ATION DATE CHECK* PERMIT AMOUNT BURCHARGEAMT. FEE CODE CEIPT# BY: FOPM8(6-29-66) THIS FORM MUST BE ACCOMPANIED BYAFACILITY/SITEAPPLICATION, FORM 'A',UNLESS A CURRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY