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STATE OF CALIFOR` RIA WATER RESOURCES CON OL BOARD FORM 'B': UNbERGROUND STORAGE TANK PROGRAM o TANK TANK PERMIT APPLICATION INFORMATIONS ... COMPLETE A SEPARATE FORM WITH THE FOLLOWING,LfiFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION D ONE ITEM ❑ ❑ ❑ 7 PERMANENTLY CLOSEDT 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE E:]8 TANK REMOVED O/ FACILITY/SITE NAME WHERE TANK IS INSTALLED: / DD GCl FARM TANK-YES❑ No N L TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-ISO SPECIFY A. OWNERS TANK ID# 3 B. MANUFACTURED BY: O _ O C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1).4S MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. IJ A. ❑ 1 MOTOR VEHICLE FUEL 2 PETROLEUM Yl C. ❑ 1 UNLEADED ❑2 LEADED 3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL UCT ❑4 GASAHOL ❑ 5JET FUEL ❑ 6 AVIATION GAS 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN E ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE W ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF �4, HAZARDOUS SUBSTANCE STORED&C.A.S.# p� �/ � C.A.S.#: 111. TANK CONSTRU TION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF I DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑ 2 SINGLEWALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER B. TANK ❑ I STEELPRON ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B IN%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ 1 R BER LINED ❑2 ALKYD LINING E]3 EPDXY LINING ❑4 PHENOLIC LINING LINING V GLASS LINING ❑6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑ NO ❑ 9905ER D. CORROSION ❑ I POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A dy1 SUCTION A U 2 PRESSURE A U 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 WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U i 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 A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER ''11/V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. QA6 P S 6 PRECISION E TESTING P S ]PRESSURE INVENTORY GRECONCILIATION P S 91VNONEE WELL�P S 95ELECTRONIC U KNOWN MONITOR P 8 99GOT GROUND WATER MONITORING WELLS VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MONET 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES [-] 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# TANK ID# elVJto lololol5l CURRENT LOCAL AGENCY F/tACILITY ID# APPR ED BY NAME' 194 L//1 PHONE#WITH AREA CODE I I i\J PERMIT NUMBER PERMIT APPROVAL PERMIT EXPIRATION DATE I•n/ CXECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: / FORM B(6-29-m) THIS FORM MUST BE ACCOMPANIED:. A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED j DATA PROCESSING COPY