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STATE OF CALIFORNI& NK WATER RESOURCESCONTROARD FORM 'B': UND GROUND STORAGE TAPR RAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY Zli NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑-4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED Q FACILITY/SITE NAME WHERE TANK IS INSTALLED: 3? - i /�/�Pl�V FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY IGC• A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),ISNOT MARKED,COMPLETE ITEM A D. I--► A ❑ 1 MOTOR VEHICLE FUEL ❑ 2PET LEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT OIL ❑ 1 PRO UCT ❑ 4 GASAHOL ❑ 5 JET FU ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑BO EMPTY ❑ 95 UNKNOWN WASTE ❑ 7 METHANOL OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.# C.A.S.#: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B,C,8 D A TYPE OF ❑ I BLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM OTSINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER STEEUIRON ❑1 STAINLESS STEEL ❑3FIBERGLASS ❑4STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑6 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR 1 RUBBER LINED ❑2 A INING F-]3 EPDXY UNING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING 19<UNLINED ❑95 UNKNOWN ❑ISLINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 PO LENE WRAP ❑2 TARORASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTIONCATHODIC 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 Am GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A &A5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 6 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U�5 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 1 VISUAL CHECK CPjS 21 NVENTORY RECONCILIATION P 8 3VADOSEWELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P&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 d / SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑VES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# C/ ` D / 16 1 1 1 O O o CURRENT LOCAL AGENCY ECILITY ID# APPROVED BY IE PHONE#WITH AREA CODE PERMIT NUMBER PERMIT OVAL TE PER TEXPIRATION CHECK# PERMIT AMOUNT SURCHARGE T. FEE CODE RECEIPT# BY: FORM B(3-7-ee) THIS FORM MUST BE ACCOMPANIE .. A FACILITY/SITE APPLICATION, FORM 'A',UNLESS ATERENT FORMA HAS BEEN FILED DATA PROCESSING COPY