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STATE OF CALIFORW WATER RESOURCES CONT BOARD FORM B': UN RGROLIND STORAGE TANK P GRAM TANK PERMIT APPLICATION INF MATION ro TANK. TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWIN I RMATION FOR EACH - 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 P ANENTLY CLOS ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED Tev FACILITY/SITE NAME WHERE TANK IS INSTALLED: /d l!�Oh FARM TANK-YES❑ NO ❑ (,V C.TI I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY w A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED a D. TANK CAPACITY INCALLONS: S0 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 EUM /// B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ OIL / ❑ 1 DUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY „~L1.I, B!5 UNKNOWN 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF �� uGC� HAZARDOUS SUBSTANCE STORED&C.A.S.q C.A.S.#: III. TANK CONSTRUCT19�1 MARK ONE ITEM ONLY IN BOX A,B,C,&D TYPE OF ❑ I IE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SING ILEO ❑4 SECONDARY CONTAINMENT ❑99 OTHER EP'l"sTEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CIAO W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ i RUBBER LINED ❑2 LINING ❑3 EPDXY LINING ❑4 PHENOLIC UNING C. INTERIOR 5 GLASS UNING UNUNEL ❑ 95 UNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE WITH iW%MET DO ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FlBERGUSS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDER BOTH IF APPLICABLE A. SYSTEM TYPE A U i SUCT A U 2 PRESSURE3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A INGLE WAL A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER Af,U 1 STEE 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 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 1VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLSS 95 U KNOWN NICMONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE S P P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE J. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? YES E] NO 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# TANKID# � qI poaLl/ 7Y 20o y CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE k WITH AREA CODE GlN<ow PERMITNUMBERPERMIT APPROVAL DATE PERMIT EXPIRATION DATE CNECK k PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT FORM B(6-29-8B) THIS FORM MUST BE ACCOMPANIEVW A FACILITY/SITE APPLICATION, FORM 'A',UNLESS AWRENT FORMA' HAS BEEN FILE DATA PROCESSING COPY