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STATE OF CALIFORN� WATER RESOURCES CONTRf 30ARD FORM `B': UND RGR OUND STORAGE TANK PRGcaRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED O FACILITY/SITE NAME WHERE TANK IS INSTALLED: o%(4q rr7� S+k_�,j FARM TANK - YES ❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPFCIFV A. OWNERS TANK ID # B. MANUFACTURED BY: U IL C. YEAR INSTALLEDD. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF (A.1), IS MARKED. COMPLETE ITEM C. IF (A.11. IS NOT MARKED. COMPLFTF ITFM In A.ZJ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM �F-] B. C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL ILF 1 PRODUCT ❑ 4 GASAHOL 5 JET FUEL ❑ 6 AVIATION GAS 0 5 HAZARDOUS ❑ 80 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 ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER B. CONSTRUCTION 1 STEEL/IRON F—]2 STAINLESS STEEL ❑ 3 FIBERGLASS F-]4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC MATERIAL B. TANK 5 CONCRETE F-16 POLYVINYL CHLORIDE F--]7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FRP ol STEEL/IRON ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 4 FIBERGLASS PIPE A U 91 NONE F-11 RUBBER LINED F-12 ALKYD LINING F-]3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING 6 UNLINED 8 100% METHANOL COMPATIBLE FRP ❑ 95 UNKNOWN A [:] ISLINING MATERIAL COMPATIBLEITH1W%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 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. F'IP'Imu ivar Vnmm 1 imn LAMULt A Ir AbV_Vt IiHUUNU, O IF UNUtHUHUUNU, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A`UJL PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER PHONE # WITH AREA CODE A ol 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 PERMIT AMOUNT A U 9 GALVANIZED STEEL A U 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 S I VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P f J Y PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON I ANM Pl:HMANtN I LY l:LUStLJ IN PLAGt 1. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH FACILITY ID # SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO ml 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 LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # AGENCY # FACILITY ID # TANK ID # ml I IFACILITY 1 O —m I E[ I -Q CURRENT LOCAL AGENCY ID # APPROVED BY NAME PHONE # WITH AREA CODE VI PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 3113/cl0 CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT # BY: / FORM B (6-29-88) THIS FORM MUST BE ACCOMPANIOMY A FACILITY/SITE APPLICATION, FORM `A', UNLESS AZ"!ARENT FORMA' HAS BEEN FILED DATA PROCESSING COPY