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STATE OF CALIFORNIA WATER RESOURCES CONTRO` ,)ARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION L.UMrLr I C A SCrAKA I r 1-UHM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY V1 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED I O / FACILITY/SITE NAME WHERE TANK IS INSTALLED: 1 C, 7 _/L (J GTI s�T6-A ' FARM TANK - YES ❑ NO TANK DESCRIPTION COMPLETE ALL ITEMS -IF UNKNOWN -SO SPECIFY _ A. OWNERS TANK ID # I B. MANUFACTURED BY: G�?�Q� S'"e j C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: TAN ONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.11. IS NOT MARKED. COMPLETE ITEM D. / A 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM Fe"i DOUBLE WALLED C. ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL F-13 CHEMICAL PRODUCT [:]4 OIL RODUCT Vl ❑ 4 GASAHOL 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY E] 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. 4: x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D A. TYPE OF Fe"i DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 INGLE WALLED ❑ 4 SECONDARY CONTAINMENT 99 OTHER B. CONSTRUCTION 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B. TANK F-] 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE F-] 7 ALUMINUM E] 8 100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER U 3 POLYVINYL CHLORIDE (PVC) U 4 FIBERGLASS PIPE F-11 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4,FHENOUC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNLINED U 7 STEEL CLAD W/FRP A U 8 100% METHANOL COMPATIBLE FRP 95 UNKNOWN A ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO ❑ ?YOTHER 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. NIF'INU INI-UKMA I IUN CIRCLE A IF ABQVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A SUBSTANCE REMAINING IN 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 UN OWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) 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 CHECK # A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER BY: V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. IP IV 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLI PJS �l/'r 4 ELECTRONIC MONITOR R - ,.S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN //�' /La 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 # SUBSTANCE REMAINING IN INERT MATERIAL? E]YES E]NO 1 GALLONS bo o �/] 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 # bo o �/] 00O CURRENT LOCAL AGENCY FACILITY ID # APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER —T—PERMIT ADPPROVA DATE PERMIT EXPIRATION DATE N � v CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT # BY: FORM B (3-7-88) THIS FORM MUST BE ACCOMPANIEDrrA FACILITY/SITE APPLICATION, FORM 'A', UNLESS A CD"ENT FORMA' HAS BEEN FILED DATA PROCESSING COPY