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STATE OF CALIFORW WATER RESOURCES CONJOL BOARD FORM 'B':NDER R U G OUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMITCHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED l� FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK - YES ❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO S6wlFY A. OWNERS TANK ID # B. MANUFACTURED BY: C. YEAR INSST"ALLLED kw( D. TANK CAPACITY IN GALLONS: 1p000 II. TANK CarafENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. ❑ 1 D UBLE WALLED C. 1 UNLEADED ❑ 2 LEADED D 3 DIESEL El CHEMICAL PRODUCT ❑ 4 OIL �1PRODUCT 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 60 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. #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D A. TYPE OF ❑ 1 D UBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SING WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER A U 95 UNKNOWN A U 99 OTHER _ 1 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 2 STAINLESS STEEL [-]1 RUBBER LINED ❑ 2 ALKY>UNING El3 EPDXY LINING F-14 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LININGNLINED A U ❑ 95 UNKNOWN A ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR PHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS RElN'FIOjZDPLASTIC jj�� PROTECTION ❑ 5 CATHODIC PROTECTION NONE ❑ 95 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 0PRESSURE INERT MATERIAL? E]YES [::] NO 1 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 LINED TRENCH A U 91 NONE A 95 UNKNOWN A U 99 OTHER BY: A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE A U 91 NONE 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 A1095 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 S 1 VISUAL CHECK 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P [)6 PRECISION TESTING Ps 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER I. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH FACILITY ID # TANK ID # LLI f I �1(,el L 1 1 -131 SUBSTANCE REMAINING IN INERT MATERIAL? E]YES [::] NO 1 APPROVED BY NA E # WITH AREA CODE 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 & SIGNATURE) DATE 1 nCeL OC.FNCY tMgF ONLY COUrnNTY # I JURISDICTION # I I I I AGENCY # E[ F -i FACILITY ID # TANK ID # LLI f I �1(,el L 1 1 -131 CURRENT LOCAL AGENCY FAC 'vD/# / , APPROVED BY NA E # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE RM// EXPIRATION D CHECK # PERMIT AMOUNTSURCHARGE AMT. FEE CODE RECEIPT # BY: FORM B (6-29-88) THIS FORM MUST BE ACCOMPANIELW A FACILITY/SITE APPLICATION, FORM `A', UNLESS AMRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY rm W im