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STATE OF CALIFORNII- WATER RESOURCES CONTRO' ZOARD FORM `B': UNDEF):rGROUND STORAGE TANK PRO a�iAM TANK TANK PERMIT APPLICATION INFORMATION } Y' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION 07YERMANENTLYCL K ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ,i- ❑6 TEMPORARY TANK CLOSURE B TANK REMOVED O�, FACILITY/SITE NAME WHERE TANK IS INSTALLED: E� S/ FARM TANK-YES❑ I I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY :10 A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN rAl I ONS In/V 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. ~Y� A. g MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED LEADED ❑3 DIESEL V ❑3 CHEMICAL PRODUCT ❑ 4 OIL R21<PRODUCT ❑4 GASAHOL ❑ 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&C.A.S.# C.A.S.#: AIM .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,h D A TYPE OF ❑ I BLEWAIl'® ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER Fe 1 STEfL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 MELCLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCPEIE ❑6 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑B 100%METNANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZEDSTEEL ❑95 UNKNOWN ❑99 OTHER ❑ LINING 6 UNLINED P-91 RIBBER LINED ❑2 ALKYO LINING ❑3 EPDXY LINING F-14 PHENOLIC LINING LINING GLASS C. fl 5 UNKNOWN LINING ❑ ❑ ❑ IS UNING MATERIAL COMPATIBLE WITH L00%MEWML7 ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑I POLYETHLENE WRAP ❑2W OR ASPHALT ❑ YIHYLWRAP ❑4 FIBERGLASS REINFORCEDPLASTIC PROTECTION ❑5 CATHODIC PROTECTION 91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A CU 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 UNED TRENCH A U 95 UNKNOWN A U 99 OTHER AU 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B IIX METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER 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 S 5 GROUND WATER MONITORING WELLS IF P S 6 PRECISION TESTING P S 7 PRESSURETESTING S 91 NONE- P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE T UGALLONS N R USED LMO/YR) 2. ESTIMATED QUANT OF 3.WAST K FILLED WITH SUBSTANCE RptA IA RIAL7 ❑YES ❑ NO THIS FORM H S BEEN COMPLETED UNDER PENALTY OF PERJU ,AND TO THE BEST OF MY KNOWLE GE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# c) 1 C2 1l1 S Uo 0 CURRENT LOCAL AGENCY FACILITY IDN AP OV BY NR/APHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL O TE If PERMIT EXPIRATION DATE CHECKS PERMIT AMOUNT I SURCHARGE ANY. FEE CODE RECEIPT N BY: FORM B(3-7-66) THIS FORM MUST BE ACCOMPANIET1TfA FACILITY/SITE APPLICATION, FORM 'A',UNLESS A NT FORMA' HAS BEEN FRED