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STATE OF CALIFORNI WATER RESOURCES CONTRf BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - Z 10 MARK ONLY Ptl NEWPERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED W '''� FACILITY/SITE NAME WHERE TANK IS INSTALLED: GY.K/G FARM TANK-YES❑ NO W I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SP CIFY GTI A. OWNERS TANK ID# B. MANUFACTURED BY: 00 C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. 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 8 C. ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑1 OIL PROD ❑4 GASAHOI ❑ 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&CAS.# C.A.S.#: t III. 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 P'SINGLEWALLED ❑4 SECONDARY CONTAINMEIFT ❑ 99 OTHER I STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 REEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL F-] 5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM F-18 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBERUI ED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ®'6 UNUNED / J/ ❑ 95 UNKNOWN A ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL9 ❑V ❑ NO OTHER D.CORROSION ❑ I POLYETHLENEWMP [:j 2 TAR OR ASPHALT ❑ 3, L WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION E]5 CATHODIC PROTECTION ❑91 NONE N6IUNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A 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 ED U 3 UNEDTRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL 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 A 19 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 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TE STING 9 7 PRESSUPE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATE DATE LAST USED(MO/YR) 2. ESTIMATE QUANTITY OF 3. STANK FILLED WITH J SUB TA FjF1EMAINING IN GALLONS T MATERIAL? ❑YES ❑ NO THINS FORM HAS BEEN COMPLETED UNDER PENALTY CfF PERJURY,AND TO THE BEST OF MY KN WLEDGE IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION k AGENCY# FACILITY ID# TANK IO k O I zz10101 v CURRENT LOCAL AOENOY FACILITY ID# APPR ED SY NAME . PHONE k WITH AREA CODE PERMIT NUMBER PERMIT APP OVAL DATE MIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHA E A FEE CODE RECEIPT# BY: / FORM B(6-29-66) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A ZURRENT FORMA' HAS BEEN FILED CIA 1A PROCESSING COPY