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STATE OF CALIFORNIA► WATER RESOURCES CONTR&BOARD FORM 'B': UN GROUND STORAGE TANK PR RAM TANK 6" TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS K ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDED PERMIT E]6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED 0 FACILITY/SITE NAME WHERE TANK IS INSTALLED: -Z b 1, GSL&N (� Je FARM TANK-YES❑ NO O 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID N B. MANUFACTURED BY: eA CI�S C. YEAR INSTALLED 0. TANK CAPACITY IN GALLONS: 57rZ b II. TANK CONTENTS IF(A.1),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 ❑2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 60 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.N C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOR A,B,C,&D A TYPE OF ❑ 1 DOUBIEWAUED ❑3 SINGLE WALLED WITH EXTERIOR UNEP ❑95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEELIIRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ B 1DD%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE E] 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER UNED El ALKYD LINING F-] 3 EPDXY LINING 4 PHENOLIC UNING C. INTERIOR LINING 5 GLASS LINING ❑6 UNUNED 95 UNKNOWN ❑ ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 RBERGUSS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC 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 / SUCTION A U 2 PRESSURE 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 DOUBLE 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 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U B 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. P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 5 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 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 SUBSTANCE REMAINING IN GALLONS 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(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION k AGENCY K FACILITY ID N TANK ID N m = = I I I / -D 1 1-31 CURRENT LOCAL AGENCY FACILITY IDN ..(( APPROVED BY NAME PHONE N WITH AREA CODE ti Y PERMIT NUMDER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK* PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: M B(6-29-am THIS FORM MUST BE ACCOMPAVY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS RRENT FORMA' HAS BEEN FILED(/" > DATA PROCESSING COPY