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STATE OF CALIFORN& WATER RESOURCES CONTRJWOARD FORM `B': UND GROUND STORAGE TANK PR RAM TANK TANK PERMIT APPLICATION INFORMATION I COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. r5"FOR-, I MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT E2 5 CHANGE OF INFORMATION ❑7 PERMANENTLY C ONE ITEM F-]2 INTERIM PERMIT F-14 AMENDED PERMIT F__] 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED M/q FACILITY/SITE NAME WHERE TANK IS INSTALLED: r�_[AI. Ga , FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-$O ECIFY 9 A. OWNERS TANK ID# B. MANUFACTURED BY: i C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: U ©O C II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. CD f A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. �UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL IJ '_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) i D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: x111. TANK CONSTRUCTION MARK ONE ITIM ONLY IN BOX A,B,C,&D A.TYPE OF LJ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER j ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASSn 4,STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC II B.TANK MATERIAL ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE [:] 7 ALUMINUM � 88 100%METHANOL COMPATIBLE FRP ' ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 9 UNKNOWN ❑99 OTHER C. INTERIOR Fl1 RUBBER LINED ALKYD LINING 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 THER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP EZ'4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABAE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A 1 SUCTION A PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A V 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A Un�FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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. I---- _/° 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 (,�}��. P S 6 PRECISION TESTING P 7 PRESSURE TESTING P S 91 NONE S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED D TE LAST USED(MO/YR) 2. ESTIM9T D QUANTITY OF 3. W TANK FILLED WITH IV 14 SUREMAINING IN GALLONS I ATERIAL, El YES ❑ NO THIS FOAM HAS BEEN COMPLETED UNDER PENALTY Ar"ff fRY,AND TO THE BEST OF MY KNO LEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# = I 1 11 1 1 1 1 ® 0 -z- LQUA ( -1 CURRENT LOCAL AGENCY FACILITY DA-, APPR VED BY AME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIe Y A FACILITY/SITE APPLICATION, FOFtM 'A',UNLFSSTMRRFNT FORMA' HAS BEEN FILED DATA PROCESSING COPY