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L BOARD , A WATER RESOURCES CO GRAM TE OF CALIFO STORAGE TANK >o STA XRGROUND Z FORM 'B' TANK PERMIT APPLICATION INFORMATION 1 ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK 'TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 3 RENEWAL PERMIT NK REMOVED O 9 N �1 NEW PERMIT ❑ 4 E ENDED PERMIT ❑6 TEMPORARY TANK CLOSURE MARK ONLY ❑ jlIb 2 INTERIM PERMIT ❑ FARM TANK-YES❑ NO ONE ITEM O . FACILITY/ ITE NAME WHERE TANK IS INSTALLED: 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SBEMI�UFACTURED BY: A. OWNERS TANK ID R D. TANK CAPACITY IN GALLONS. C.YEAR INSTALLED IS NOT MARKED,COMPLETE ITEM D. DIESEL IF(A•1),IS MARKED,COMPLETE ITEM C.IF lA.t), C ❑1 UNLEADED ❑2 LEADED II. TANK CONTENTS B. ❑5 JET FUEL fi AVIATION GAS ❑2 PETROLEUM ❑4 GASAHOL A. 1 MOTOR VEHICLE FUEL rYr PRODUCT ❑3 CHEMICAL PRODUCT ❑4 OIL LJ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BEL 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ ❑5 HAZARDOUS ❑ C.A.S.k: D OF HAZARDOUS SUBSTANCE STORED&C.A.S.N III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D ❑M UNKNOWN ❑ 1 OOUBLEWALLED ❑3 SINGLE WALLED WITH EKTEOIOR IN' ❑M OTHER A.TYPE OF -I $INOIEWALLED ❑4 SECONDARY CONTAINMENT SYSTEM L.`;` 3 FIBERGLASS ❑4 STEEL CIABWIRBERGLASS REINFORCED PLASTIC 1 5TEELIIRON ❑2 STAINLESS STEEL 7 ALUMINUM ❑8180°6 METHNIOL COMPATIBLE FRP RIDE B.TANK ❑5 CONCRETE 0 111 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER MATERIAL ❑y BRONZE ❑ ❑2 AU(YD LINING ❑3 EPDXY UNNG ❑95 UNKNOWN 1 RUBBER LINED , t C. INTERIOR NUNEO ❑ ❑.pB.BTHEP ❑5 GLASS LINING DYES � Lam _ LINING ❑IS LINING MATERIAL COMPATIBLEWITH 100%METHANOL? ❑^3 V�INYLWRAP ❑4 FIBERG D.CORROSION ❑ POLYETHLENEWRAP LASS R'_"FOTCPIPLASTIC 1 [1]2TAONE ASPHALT KFIOWN ❑M OTHER PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE CABLE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER IV. PIPING INFORMATION CIRCLE A IF AABOVZ PF UN U IF UNDERGROUND,BOTH IF APPu A.SYSTEM TYPE A u sucrloN B.CONSTRUCTION A U 1 BINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE 4 FIBERGLASS PP AAU U91 NONE A U 1 STEEL/IRON A U 2 STAINLESS BTEEL A U 3 POLWINYL CHLORIDE PVC) N OTHER A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP C. MATERIAL A U 5 ALUMINUM 5 UNKNOWN A U 99 OTHER A U 9 GALVANIZEDSTEEL U V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMAW LEAK DETECTION SYSTEM MUST BE CIRCLM p 5 1VISUAL CHECK P S 21NVENTORV RECOOT ER NCILIATION P S 3VADOSE WELLS P 9 9FL.E GTROWNMO111TOR P 8 559OTHER GR0 WATER MONITORING WELLS P S 6 PRECISION TESTING P S I PRESSURETESTING P S 91 NONE V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE s wAs TANK FlLLEO wrFH )� 2 SUBSTANCE QUANTITY OF INERT MATERIAL? YES / /*0 1.ESTIMATED DATE LAST USED(MO/YR) SUBSTANCE REMAINING IN GALL /�/ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST KNO*LEDGE IS TRUE AND CORRECT. DATE APPLICANT'S NAME(PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY FACILITY IT AGE TANK ID k COUNTY k JURISDICTION k APPROVED BY AME PHONE X WITH AREA CODE CURRENT LOCAL AGENCY FACILITY IDX 1 ' ' ^)` PERMIT APPROVAL DATE I�JPERMIT E`XPIR47E PERMIT NUMBER SURCHARGE AMT. FEECODE °IPTX CNECKX PERMIT AMOUNT BY; IIId FORM 3(6.29-6B) THIS FORM MUST BE ACCOMPANIED SrA FACILITY/SITE APPLICATION, FORM'A',UNLE;M FORMA, HAS BEEN FILED DATA PROCESSING COPY