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STATE OF CALIFORNIO WATER RESOURCES CONTRO' -OARD FORM 'B': UNDEAtROUND STORAGE TANK PROMAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 5 FACILITY/SITE NAME WHERE TANK IS INSTALLED: ,h no ee TV FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# �3 r' B. MANUFACTURED BY: GC, C. YEAR INSTALLED Zt. D. TANK CAPACITY IN GALLONS W II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. 00 CLE B. ED 3 DIESEL A F-1 3 CHEMICAL PIRODUCTL� OIILTROLEUM �RODUCT C ED 4 UNLEADED GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS w ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑7 METHANOL 5a4g'OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF L r Q '• / - - p' HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: O O x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,8 D A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN i SYSTEM SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/IRON ❑2 STAINLESSSTEEL ❑3 FIBERGLASS ❑4 STEEL CND W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑6 POICHLORIDE F-17 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN [-]99 OTHER ❑ C. INTERIOR I RUBBER LINED ❑2 ALKYD LINING F-13 EPDXY UNING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING f 6 UNLINED ❑95 UNKNOWN !i ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO rZIN16THER Ze-l-"' D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT 03 V WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION [-]5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A CE 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 ACU 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 GALVANIZEDSTEEL A U 95 UNKNOWN A U 99 OTHERI, V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 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(MO/YR) 2. ESTIMATED QUANTITY OFGAlLON6 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? L]YES ❑NO 1 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FACILRY 3 IDM APPROVED BY-T��E PHONE#WITH AREA CODE 5 PERMIT NUM R PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEECODE LRi IPT# BY: �� FORM B(3-7-66) THIS FORM MUST BE ACCOMI A FACILITY/SITE APPLICATION, FORM 'A',UNLESS AW, RENT FORMA' HAS BEEN FILED