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STATE OF CALIFORNI& WATER RESOURCES CONTRCSOARD FORM `B': UND GROUND STORAGE TANK PR m TANK PERMIT APPLICATION INFORMATION ti TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. °'" 10 ❑ 5 CHANGE OF INFORMATION F]7 PERMANENTLY CLOSED TANK 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Q MARK ONLY ❑ ❑ q AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED ONE ITEM []2 INTERIM PERMIT FARM TANK-YES❑ NO � FACILITY/SITE NAME WHERE TANK IS INSTALLED: le,61 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SBE MFY ANUFACTURED BY: A. OWNERS TANK ID# P D. TANK CAPACITY IN GALLONS: O C. YEAR INSTALLEDd II. TANK ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITE 2 B. LEADED 3 DIESEL A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑3 CHEMICALPRODUCT ❑ 4 OIL yl 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.W HAZARDOUS SUBSTANCE STORED&C.A.S.# III. TANK CONSTR CTION MARK ONE ITEM ONLY IN BOX A,B,C,&D BLE WALLED ❑3 S14GLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN A.TYPE OF 1 DW ❑99 OTHER SYSTEM F-12 SINGLE WALLED ❑4 SECONDARY CONTAIN MEM 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B 160%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD UNING ❑3 EPDXY LINING ❑ 95 UNKNOWN NING C.INTERIOR E]5 GLASS LINING ❑6 UNLINED LINING ❑ IS LINING MATERIAL COMPATIBLE WITH ion METHANOL? []YES ❑ NO 99 OTHER D. CORROSION POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYLWRAP ❑ 4 RBERGLSS REINFORCED PLASTIC NONE LrJ�7/ [:] ❑95 UNKNOWN ❑ 99 OTHER PROTECTION 5 CATHODIC PROTECTION 91 IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE B18NONE A U 95 UNKNOWN A U 99 OTHER A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A(U SINGLE WALLED A U 2 DOUBLE WALLED A U 1 STEEL/IRON A U 2 STAINLESS STEEL A�/UU 3 3�_POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL p U g GALVANIIZED STEEL A U 6 CUONCRETE A Y 99 OTHER A U B 100%METHANOL COMPATIBLE FRP V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. I/ p 1 VISUAL CHECK 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS �j'{TT'� 6 PRECISION TESTING p 8 7 PRESSURE TE STING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLED WITH 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF INERT MATERIAL? YES ❑ NO SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY FACILITY ID# TANK ID# COUNTY k JURISDICTION � AGENCY#a� /' APPROVED BY NAME PHONE X WITH AREA CODE CURRENT LO CAL AGENCY FACILITY ID# p -)� G/-7 NUM .0,T- PERMIT APPROVALOATE PERMIT EXPIRATION DATE PERMI BER CHECK X PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: /7 FORM B(6-29-66) THIS FORM MUST BE ACCOMPANIED BY A FACILITYAPPLICATION, FORD A',UNLESS A PENT FORMA' HAS BEEN FILED DATA PRO