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w STATE OF CALIFORNI WATER RESOURCES CONTRgARD FORM `B': UNDE GROUND STORAGE TANK PRO AMnb TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 21 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: Z22 I Cf 0 FARM TANK-YES❑ NO y I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ION l(1K B. MANUFACTURED BY: (� C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS, L000 II. TANK 9ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED LEADED 3 DIESEL 0 ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL �ROOUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ BO 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&C.A.S.# C.A.S.W xlll. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER ® 1 STLEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLADW/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCHETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER ❑ I RUBBER LINED ❑ 2 ALKYD LINING 5� 3 EPDXY LINING El PHENOLIC LINING C. INTERIOfl LINING F-15 GLASS LINING El6 UNLINED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLEWITH iw%mETHANOL? ❑YES V J NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TARORASPHALT ❑3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE �K 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,190TH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 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 WIFRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A (9 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;01 I VISUAL CHECK O S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELLS P PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE F77�� ATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3-WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES�❑:N]O GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE:BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME{PRINTED&&GNATURE) DATE LOCAL AGENCY USE ONLY EPERMIT JURISDICTION# AGENCY# FACILITY ID# TANK ID# o r o , AGENCY FACILITY ID fl APPROVED BY NAMES-/^t.� PHONE#1 WITH AREA CODE IA � � 711 Uf8 9/� \4\\\\ PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PERMIT AMOUNT SURCHARGE AMT. FEE CODE *RECEIPT N BY: FORMB(3-7-ss) THIS FORM MUST BE ACCOMPANIED „FACILITYISITE APPLICATION, FORM 'A',UNLESS A T FORMA' HAS BEEN FILED DATA PROCESSING COPY