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STATE OF CALIFORN WATER RESOURCES CONTR OARD NDGROUND STORAGE TANK PRAM FORM B . U iffier - �a TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. d- MARK ONLYVINTERIM PERMIT ❑ 3 RENEWALPERMIT C ANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS ONEITEM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO I. TANK (DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# C/-vAe B. MANUFACTURED BY: 41 G. YEAR INSTALLED D. TANK CAPACITY iN GALLONS. zo II. TANK CO NTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A,1),IS NOT MARKED,COMPLETE ITEM D. A. OTOR VEHICLE FUEL ❑ 2 PETROLEUM BE44-1`I C. ❑ 1 UNLEADED ❑ 2 LEADED DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 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&G.A.S.It C.A.S.#: xlll. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUG E WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM INGLEWALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER EELIIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL GLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE E] 5 POLYVINYLCHLORIDE ❑ 7 ALUMINUM E] B 19496 METHANOL COMPATIBLE FRP 8.TANK R5 MATERIAL ❑ 9 BRONZE ❑ 14 GALVANIZED STEEL D 95 UNKNOWN ❑99 OTHER F-11 RUBBER LINED 2 ALKY INING F-] 3 EPDXY LINING 4 PHENOLIC LINING C. INTERIOR ❑ LINING 5 GLASS LINING UkeLINED ❑95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION AU PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 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 C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 195 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 S I VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 5 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE El:. ESTIMATED DATE LAST USED O/YR 72. STIMATED QUANTITY OF 3. WAS TANK FILLED WITH UBSTANCE REMAINING IN INERT MATERIAL? ❑ YES NO GALLONS THIS FORM NAS BEE 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 ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# LL I I ® iz r I'o -) CURRENT LOCAkAGENCY FACILITY ID# APPROVED BY NAVE PHONE#WITH AREA CODE r11 PERMIT NUMBER PERMIT A ROVAL DA PER EXPIRATI DATE CHECK# PERMIT AMOUNT SURCHARG AMT. FEE CODE RECEIPT# BY: FORM B(3-7-m) THIS FORM MUST BE ACCOMPANIE I FACILITY/SITE APPLICATION, FORM `A',UNLESS A NT FORMA' HAS BEEN FILED DATA PROCESSINGCOPY