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rvRfig ; TATE OF CALIFORNIJ WATER RESOURCES CONTBOARD ORM 'B': UN GROUND STORAGE TANK PR RAM ' ANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWIN NFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM [-]2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 11,f FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I® A. OWNERS TANK ID vzv B. MANUFACTURED BY: ' G YEAR INSTALLED D. TANK CAPACITY IN GALLONS: A 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 ❑ 2 P EUM 61 C* ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL F--] 3 CHEMICAL PRODUCT 4 OIL ❑ 1 P5PKCT ❑ 4 GASAHOL ❑ 5 JET EL ❑ 6 AVIATION GAS E] 5 HAZARDOUS ❑80 EMPTY E] 95 UNKNOWN WASTE ❑ 7 METHANOL 9 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# CA.S.#: All. TANK CONST UCTION MARK ONE ITEM ONLY IN BOIL A,B,C.8 D A. TYPE OF Ej�rDOUBLE WALLED ❑3 SINGLE WALLED WITH DKTERIOR LINEA ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASSSTEEL CUD W/RBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5CONCRETE ❑6 POLYVINYL CHLORIDE ❑7AMM"y. ❑8100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL AWN ❑99 OTHER ❑ 1 RUBBERUNED ❑2 LINING F-13 EPOKYLINING F' ;"^LIC LINING C. TERIO IN NG R ❑ 5 GLASS UNING UNLINED - / AOWN ❑IS UNING MATERIALCOMPATIBLE WITH 1W%METHANOL? I JOE$ ❑ NO u99 OTHER D.CORROSION F-11 POLYETHLENEWRAP ❑2 TAR OR ASPHALT tF-1 3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONEUNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A CIS LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) AID FIBERGLASS PIPE C.MATERIAL A U 5 ALUMINUM A U •1NCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL .NKNOWN 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 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLSOP S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS All P S 6 PRECISION TESTING P S 7 PRESSURE TESTING 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 OF3.WAS TANK FILLED WITH GALLONS A / SUBSTANCE REMAINING IN INERT MATERIAL? El YES ONO THIS FORM HAS 6EEN 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# 3 t' I o I �) I / 1 9 J o ol CURRENT LOCAL AGENCY FACILITY IDN APPROVED BYME PHONE»WITH AREA CODE S%G s' PERMIT NUMBER PERMIT APPROV�DATE PER IT EKPIRATIO CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: - AOL FORM B(3-7-BB) THIS FORM MUST BE ACCOMPANIED _ - .FACILITY/SITE APPLICATION, FORM 'A',UNLESS A - 'NT FORMA' HAS BEEN FILED DATA PROCESSING COPY