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STATE OF CALIFORN +' WATER RESOURCES CONTR OARD FORM `B': UNDO GROUND STORAGE TANK PRORAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION F-1 7 PERMANENTLY CLOSED TANK ONE ITEM LI 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT L_J 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: gou&}. G l'rcft q I S , FARM TANK - YES ❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. OWNERS TANK ID # ��' I B. MANUFACTURED BY: u N K C. YEAR INSTALLED ( '5 D. TANK CAPACITY IN GALLONS: ; on"o II. TANK CONTENTS IF (A.11. IS MARKED. COMPLETE ITEM C. IF (A-11- IS NOT MARKED- COMPLETE ITEM o_ A. .0 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. �S1 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL I?J 1 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. #: x111. 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 X 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER 3 GRAVITY A U F-]1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE F-]6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM E:]8 100% METHANOL COMPATIBLE FRP 3 LINED TRENCH A(D ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL D�r95 UNKNOWN ❑ 99 OTHER A F-11 RUBBER LINED El2 ALKYD LINING F-13 EPDXY LINING [:]4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNLINED A 5�r95 UNKNOWN A ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE C995 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE AU 1 SUCTION A U 2 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 A(D 95 UNKNOWN A U 99 OTHER HAS BEEN FILED A U 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 8 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A GU 95 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. 0l PS 1 VISUAL CHECK OP S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 06 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 OF 3. WAS TANK FILLED WITH PERMIT AMOUNT SUBSTANCE REMAINING IN INERT MATERIAL? [:]YES [:]NO R GALLONS I THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, 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 # lolo aZI Lo00 --Ll I CURRENT LaAGENCY FACILITY ID # AP VED B ME PHONE # WITH AREA CODE La�gAL PSV 01,L01 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE R FORM B (3-7-88) ECEIPT # BY A FACILITY/SITE APPLICATION, FORM `A', UNLE BY: COUNTY # JURISDICTION # AGENCY # FACILITY ID # TANK ID # lolo aZI Lo00 --Ll I CURRENT LaAGENCY FACILITY ID # AP VED B ME PHONE # WITH AREA CODE La�gAL PSV 01,L01 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE R FORM B (3-7-88) THIS FORM MUST BE ACCOMP BY A FACILITY/SITE APPLICATION, FORM `A', UNLE ..URRENT FORM `A' HAS BEEN FILED DATA PROCESSING COPY _ W C2 i�