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STATE OF CALIFORVIA WATER RESOURCES CONAL BOARD � J FORM 'B': 1.14MRGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATIONm COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PE MANENTLY CLOSED`TANK ONE ITEM ❑ 2 INTERIM PERMIT4 AMENDED PERMIT ❑ ❑6 TEMPORARY TANK CLOSURE [jwjTANK REMOVEQ FACILITY/SITE NAME WHERE TANK IS INSTALLED: ko G FARM TANK-YES[0_j] NO /-( 1. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY .p A. OWNERS TANK ID# B. MANUFACTURED BY dkl C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: O 0 (m II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. CJ1 A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM TW C. ❑ 1 UNLEADED 2 LEADED DIESEL ❑ 3 CHEMICAL PRODUCT ❑q OIL PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWNASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&CA S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLEWALLE ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEMSINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B MATERIAL ❑ 5 CONCRETE 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM E] 8100%METHANOL COMPATIBLE FOP ❑9 BRONZE 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR 1 RUBBER LINED 2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING UNLINED E�k�UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WIT 100%METHANOL9 ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 T OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NO UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE AIFABOV ROUND, UIFUNDERGROUND,BOTHIFAPPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 ESSURE 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 DO BLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAT ESS STEEL A U 3 POLYVINYL CHLORIDE PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRkTE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNO N A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, R S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3DOSEWELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S Sit P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED N PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED DUANTI OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINI IN GALLONS INERT MATERIAL? ❑YES E] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,A\D 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# ® = 10 10 11 35 OO 0 CURRENT LOCAL AGENCY F CILITY IDN APPROVEO BY NA E PHONE#WITH AREA CODE A s 10 PERMITUMBER PERMIT APPROVAL DATE ERMIT EXPIRATION DATE CHECK♦ PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIED lvftw;ACILRY/SITE APPLICATION, FORM 'A',UNLESS A CU NT FORM'W HAS BEEN FILED DATA PROCESSING COPY