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` 11 STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _�^ Z, MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 10 ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLO SURE ❑6 TANK REMOVED 1 FACILITY/SITE NAME WHERE TANK IS INSTALLED: Q FARM TANK-YES❑ NO ❑ C-" I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK IDN Y B. MANUFACTURED BY: G4C. 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. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. ❑ 1 UNLEADED ❑2 LEADED 3 DIESEL F-13 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑60 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAMEOF HAZARDOUS SUBSTANCE STORED&CAS.RAla C.A.S.R: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLEWAUFD ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ffl-24'SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 51EEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/RBERGUSTI SS REINFORCED PLASTIC B. TANK MATERIAL F-15 CONCRETE 6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑B 100%METHANOL COMPATIBLEFRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑I RUBBFRUNED ❑2 ALKYD UNING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS UNING ❑6 UNLINED UNKNOWN )�J [:] ISUNING MATERIAL COMPATIBLE WITH IDD%METHANOL? ❑YES [-]NO OTHER U .9 D. CORROSION ❑I POLYETHLENE WRAP ❑2 TAR ORASPHALT ❑3 V WRAP F-14 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION 91 NONE"----- �95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GRaUNE), U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A ..1 SUCTION A U 2 PRES9L 4 A V t3 GRAVITY A U 91 NONE A 5 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 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM Ab= A U 7 STEEL CLAD W/FRP A U e 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A A U 99 OTHER )" V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. T' P8 1 VISUAL CHECK 108 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS -/1 P SPRECISION TESTING P 10 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 OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING INGALLONS INERT MATERIAL? DYES ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE i LOCAL AGENCY USE ONLY COUNTY R JURISDICTION E AGENCY R FACILITY IDM TANK ID k CURRENT LO ADEN Y FACILAT 1 APPROVE BY NAME PHONE M WITH AREA CODE PERMIT UMBER Ij-' l PERMIT APPROVAL DATE PE IT EXPIRATION DATE ECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# 8Y: FORM B(8-29-88) THIS FORM MUST BE ACCOMPANIED-STA FACILITY/SITE APPLICATION, FORM'A',UNLESS A ENT FORMA' HAS BEEN FILED _ DATA PROF SING COPY_.