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STATE OF CALIFORNI6 WATER RESOURCES CONTRWOARO FORM `B': UNDERGROUND STORAGE TANK PRO RAMm ' TANKTANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. " Q MARK ONLY ❑ 1 NEW PERMIT F� 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONE ITEM �2 INTERIM PERMIT F-14 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED N FARMTANK-YES[ NO FACILITY/SITE NAME WHERE TANK IS INSTALLED: 1p (p I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY c:) qq y CD A. OWNERS TANK ID R B. MANUFACTURED BY: V keel c-C7 r n / O. YEAR INSTALLED 7 D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL F-] 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED 3 DIESEL 3 CHEMICAL PRODUCT F-� 4 OIL PRODUCT ❑ 4 GASAHOL 5 JET FUEL 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY E] 95 UNKNOWN E] 2 WASTE E] 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.N: HAZARDOUS SUBSTANCE STORED&C.A.S.k 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED F-�3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SINGLE WALLED F--] 4 SECONDARY CONTAINMENT 99 OTHER 1 STEEL/IRON ❑ 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CUD WIFIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE F-1 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM 8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL 0 95 UNKNOWN E]99 OTHER 1 RUBBER LINED ❑ 2 ALKYD LINING ❑3 EPDXY LINING E]4 PHENOLIC LINING C. INTERIOR5 GLASS LINING 6 UNLINED 95 UNKNOWN LINING F] IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES [:] NO 99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP F-12 T ORASPHALT 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 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 UNEDTRENCH A U 91 NONE 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 FISERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A(Up 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. Ly � P S-P S 1VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P S 4ELECTRONIC MONITOR P S SGROUND WATER MONITORING WELLS `Y 6 PRECISION TESTING S 7 PRESSURETESTING 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 SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? YES ONO 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) DATE LOCAL AGENCY USE ONLY COUNTY B JURISDICTION N AGENCY M FACILITY ID R TANK ID N Fol 6 / � 5 � Doo / CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE k WITH AREA CODE f �oa� PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK k PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY. FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY