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STATE OF CALIFORN WATER RESOURCES CONTRr 30ARD �� sA FORM `B': UNI GROUND STORAGE TANK PROuRAM ....'` T TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. `._o a MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT L?<CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO ONE ITEM F-12 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED / FACILITY/SITE NAME WHERE TANK IS INSTALLED: ti 5, FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A OWNERS TANK ID# O B MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: S-6 d 11. 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 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL N ❑ 3 C EMICAL PRODUCT ❑ 4 OIL F-11 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN 'WASTE ❑ 7 METHANOL �6THER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: x111. 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 2r2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER Fkri STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C.INTERIOR F-11 RUBBER LINED F-12 ALKYD LINING ❑ 3 EPDXY LINING F-] 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING UNLINED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE42-11"UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH 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 U 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 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A P5 UNKNOWN A U 99 OTHER . LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORINGWELLS P S PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER d7— VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED TE LAST USED(MO/YR) 2. ESTIMATED QUANT OF 3. WAS TAN FILLED WITH SUBSTANCE E N GIN IN T T AL7 ❑YES [:] NO GALLONS THIS FOPM HAS BEEN COMPLETED UNDER PENALTY OF PERJ RY,AND TO THE BEST OF MY KNOWLE E, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY F JURISDICTION# AGENCY# FACILITY ID# TANKID# E[ AGENCY FACILITY ID# APP O 13 Y l PHONE#WITH AREA CODE A81 A4 PERMIT NUMBER PERMIT APPROVAL DATIE PERMIT EXPIRATION DATE 1 .411 CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIE Y A FACILITY/SITE APPLICATION, FORM 'A',IJNLrSSATMRFNT FORMA' HAS BEEN FILED J DATA PROCESSING COPY