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STATE OF CALIFORNIIA WATER RESOURCES CONTROI ')ARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM mo TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. .� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT Rr5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM �2INTERIM PERMIT F--] 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 7I/ FACILITY/SITE NAME WHERE TANK IS INSTALLED: Gam- Ne]-J- skV/LC.E 19 FARM TANK-YES❑ NO G to I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERSTANKID# K B. MANUFACTURED BY:Q _ I & C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS. I Z QOU ~ W 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. [01 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. �l UNLEADED ❑ 2 LEADED ❑3 DIESEL A ❑3 CHEMICAL PRODUCT ❑ 4 OIL E0PRODUCT ❑ 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.#: .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF I v I I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ i STEEUIRON ❑2 STAINLESS STEEL L—Lojl FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE F—] 7 ALUMINUM 8 IW%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER UNED ❑ 2 ALKYD LINING ❑3 EPDXY LINING ❑ 4 PHENOLIC UNING LINING ❑5 GLASS LINING Z6 UNLINED ❑95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH IOD%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP (�4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHOOIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 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 U 95 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) AO4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%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. P®1 VISUAL CHECK B 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS PO4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTI* 8 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OFOALlONB 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRI NTED&SIGNA ) DATE LOCAL AGENCY USE ONLY COUNTY* JURISDICTION# AGENCY# FACILITY IDM TANKID# CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE#WITH AREA CODE -r, � ti PERMITNUMBER PE APPROVAL DATE PERMIT EXPIRATION DATE CHECK n PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORMB;3-em THIS FORM MUST BE ACCOMPANIED SYAFACILITY/SITE APPLICATION, FORM 'A',UNLESS A` RRENT FORMA' HASBEENFILED DATA PROCESSING COPY