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STATE OF CALIFORNIf WATER RESOURCES CONTRC 'OARD FORM `B': UNDEA`GROUND STORAGE TANK PRO' RAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT 3 RENEWALPERMR EKCHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED /y FACILITY/SITE NAME WHERE TANK IS INSTALLED: 3 Ch- FARM TANK-YES❑ NO .), I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 0 A. OWNERS TANK ID a B. MANUFACTURED BY: 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. C4 A_ ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ i UNLEADED ❑ 2 LEADED ❑ 3 DIESEL 00 ❑3 CHEMICAL PRODUCT F d OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑60 EMPTY ❑ 95 UNKNOWN WASTE ❑7 METHANOL OTHER(DESCRIBE IN ITEM D,BELOW) 0, IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF q_ HAZARDOUS SUBSTANCE STORED 8 C.A.S.It 5' 0 ; / C.A.S.#: 0✓ -111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM V 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEOURON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 UMINUM ❑6100%METHANOL COMPATIBLE FAR li MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBERUNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑ 4 PHENOLIC LINING ❑5 GLASS UNING [:]6 UNLINED LINING UN NOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%MERIANOL? ❑YES ❑ NO ED4 OTHER D. CORROSION 1 PROTECTION ❑ 5 CATHODIC PROTECTION ❑91NONE ASPHALT 3 VINYL E 9 UNKNOWN ❑99P 4 OTHER SS REINFORCED PLASTIC IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF U95NDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 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 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 C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A0 5 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. yL. P 8 / VISUAL CHECK IOS 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS �T P P 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 IMO/YRI 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E-]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 S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# dl Ololokrj CURRENT LOCAL AGENCY FACILRY ID# APPROVED BY NAMS,LJ PHONE#WITH AREA CODE JD c Tf} S 97et PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMR AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM R(3-7-33) TRIS FORM MUST BE ACCOMPANY A FACILITY/SITE APPLICATION, FORM'A',UNLESSJA RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY