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STATE OF CALIFORN& WATER RESOURCES CONTROARD FORM 'B': UND GROUND STORAGE TANK PR RAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 MANENTLY CLOSEDTA K ONE ITEM [:]2INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED lo FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO 10 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY tilt A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED tqD. TANK CAPACITY IN GALLONS: Q OO CA) 11. TANKLATENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. co o MOTOR VEHICLE FUEL D 2fiETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL 3 CHEMICAL PRODUCT 4 OIL �RODUCT ❑4 GASAHOL ❑ 5 J FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN WASTE ❑ 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF /e HAZARDOUS SUBSTANCE STORED&C.A.S.# G{//v+r ©/r/ L C.A.S.M All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A TYPE OF ❑ I UBLE WALLED F-1 3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED F-14 SECONDARf CONTAINMENT ❑99 OTHER STEELARON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEELCLAD WFIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 IW%METHANOLOOMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑2 AO(YO LINING ❑3 EPDXY LINING n 1 MENOUCUNING C.INTERIOR ❑5 GLASS LINING ❑6 UNLINED � 95 UNKNOWN LINING ❑ IB LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VI WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑ 91 NONE 5 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 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A Jj 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUMA 6 CONCRETE A U 7 STEELCLADW/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 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 8 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 O` I P 8 6 PRECISION TESTING S 7 PRESSURE TESTING P 8 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 DUANTITY OF 3.WAS TA NK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? DYES [:] 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# JURISDICTION# AGENCY# FACILITY ID# TANK IO# CURRENT LOCAL AGENCY FACILITY ID# ( APPROVED BY NAME PHONE X WITH AREA CODE K=AAO1 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK X PERMIT AMOUNT RCHARGE AMT. FEE CODE RFLFIPT# BY: fN� FORM B(3-7-fie) THIS FORM MUST BE ACCOMPANIED EVA FACILITY/SITE DATA PPROCESS NORCOPYA',UNLESS A .ENT FORMA' HAS BEEN FILED G',2t1'