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STATE OFICALIFORNI# WATER RESOURCES CONTROARD F RM `B': UNDERGROUND STORAGE TANK PROGRAM 'A O TA KIV ) TANK PERMIT APPLICATION INFORMATION off -11111151% Q-/ COMPLETE A SEPARATE FORM WITH THE FOLLOWIN INFORMATION FOR EACH TANK.`"��:F�R='� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TAN ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 6 z1. 2- FARM TANK -YES ❑ NolEr 1. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. OWNERS TANK ID # B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: TANK L'InNTFNTS IF re 1\ IS MAwrm COMPLFTF ITFM C_ IF (A_11_ IS NOT MARKED. COMPLETE ITEM A.rV 1 MOTOR VEHICLE FUEL F-12 PETROLEUM Vl C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL RODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 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 CONSTRXICTION MARK ONE ITEM ONLY IN BOX A, B, C, & D A. TYPE OF IV 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 INGLEWALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER CURRENT LOCAL AGENCY FACILITY ID # 1 STEEL/IRON ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK K5 CONCRETE ❑ 6 POLYVINYL CHLORIDE F-]7 ALUMINUM [:j6 100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ HENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNLINED A 95 UN OWN 7 STEEL CLAD W/FRP A U ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO ❑ 99 HER D. CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. FIFINU INFUKMA7 IUN CIRCLE A IF GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE 3. WAS TANK FILLED WITH A. SYSTEM TYPE ALLl SUCTION A 2 PRESSURE AGRAVITY CURRENT LOCAL AGENCY FACILITY ID # A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U SINGLE WALLED A U 2 DOUBLE WALLED A U INED TRENCH A U 91 NO U 95 UNKNOWN A U 99 OTHER PERMIT EXPIRATION DATE A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) U BERGLASS 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 A U 95 UNKNOWN A U 99 OTHER LtAK Ut 1 tIL. 1 BUN 5T, 1 tM CIRCLE P FOR PRIMARY, OR 5 FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WE S P 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. 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 # SUBSTANCE REMAINING IN INERT MATERIAL? [:]YES [:]NO 1 GALLONS CURRENT LOCAL AGENCY FACILITY ID # 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 Lnr-AL AGENCY USE InNLY COUNTY # JURISDICTION # AGENCY # FACILITY ID # TANK ID # CURRENT LOCAL AGENCY FACILITY ID # APPROVED BY NAME PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE • CHECK # PERMIT AMOUNTQURCHARGE AMT. FEE CODE PFCEIPT # BY: FORM B (6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A', UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY 10 C.TI m