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STATE OF CALIFORNI& WATER RESOURCES CONTROARD .3 FORM 'B': UND GROUND STORAGE TANK PRO AM ' - w' 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 PERMANENTLYCL ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED CJL> FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES NO IV I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY � A. OWNERS TANK ID R O3 B. MANUFACTURED BY:( u_41� C. YEAR INSTALLEDtom/ D. TANK CAPACITY IN GALLONS: ODD II. TANK CONTENTS IF(A./),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. - 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. ❑ 1 UNLEADED Eq'2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL R51 PRODUPT ❑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 NAMEOF HAZARDOUS SUBSTANCE STORED&C.A.S.# -4A C A.S.#, III- TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ©2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER lf�l STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 MEL CLAD W/FIBERGLASS REINFORCEDNSTIC B. TANK ❑ 5 CONCRETE E]6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR 1 RUBBER LINED E]2 AUKYD LINING ❑3 EPDXY LINING E] 4 PHENOLIC LINING LINING ❑5 GLASS UNING [w�6 UNUNED ❑ 95 UNKNOWN '-� ) ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO OTHER f� D.CORROSION ❑ I POLYETHLENEWRAP 2 TAR OR ASPHALT ❑3 VINYL WRAP E]4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMA ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER S. CONSTRUCTION f_�IA SINGLE WALLED A U 2 DOUBLE WALLED A U 3 UNEDTRENCH A U 91 NONE A U 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 A U 91 NONE C. MATERIAL A U 5 ALUMINUMNCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL U 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. l' P VISUAL CHECK P 2 INVENTORY RECONCILJATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS y P S PRECISION TESTIN 8 7 PRESSURE TEST INC P 8 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMAT D DATE LAST USED(MO/YR) 2. ESTIMATED QUANT OF 3.WAS TA K FILLED WITH SUBSTANCE REM I IN INF�RT RIAL? ❑YES ❑ NO 014 , GALLONS �L� THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PER URY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT, APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID N = = = I6 1 D a 13 1 0o 10 CURRENT LOCAL AGENCY FACILITY ID# APPR VED BY ME PHONE N WITH AREA CODE �_ 4� ld / PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECKN PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPTN BY: n �i R"'S RS' THIS FORM MUST BE ACCOMPANIED by A FACILITY/SITE APPLICATION, FORM `A',UNLESS A �`RRENT FORMA' HAS BEEN FILED 1 DATA PROCESSING COPY `"