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STATE OF CALIFORNIA WATER RESOURCES CONTROOPARD <br /> FORM `B': UNDERGROUND STORAGE TANK PROGRAM <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 10 <br /> ONE ITEM �'TPERMANENTLY CLOSED'TANK <br /> 2 INTERIM PERMIT � q AMENDED PERMIT D 6 TEMPORARY TANK CLOSURE �e TANK R ED ' <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: Q n 10 n .J�- � k n. FARM TANK ESE] NO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A, OWNERS TANK ID# 1 CI"'I �l�cT +7 c n <br /> LVV ice. B. MANUFACTURED BY: n CA) <br /> C. YEAR INSTALLED L D. TANK CAPACITY IN GALLONS: U VL <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL �2 PETROLEUM B. C. ❑ 1 UNLEADED 0 2 LEADED 3 DIESEL <br /> 3 CHEMICALPRODUCT D 4 OIL 1 PRODUCT 0 4 GASAHOL 5 JET FUEL D 6 AVIATIONGAS <br /> 5 HAZARDOUS 80 EMPTY 95 UNKNOWN 2 WASTE 7 METHANOL J;e '8 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED 8 C.A.S.# y1 <br /> 1 l C.A.S.a: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A. TYPE OF ❑ 1 DOUBLE WALLED 0 3 SINGLE WALLED WITH EXTERIOR LINER 2-95 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> B.TANK ❑ I STEEL/IRON 2 STAINLESS STEEL D 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCEDPLASTIC <br /> MATERIAL ❑5 CONCRETE fi POLYVINYL CHLORIDE 7 ALUMINUM 8 100%METHANOL COMPATIBLE FRP <br /> ❑ 9 BRONZE 10 GALVANIZEDSTEEL L"9 UNKNOWN D 99 OTHER <br /> C. INTERIOR ❑ I RUBBERLINEO 2 ALKYD LINING f 3 EPO%YLINING 4 PHENOLIC LINING <br /> LINING ❑5 GLASS LINING 6 UNLINED - 95 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? 0 YES ❑ NO �OTHE <br /> D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TARORASPHALT 0 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION ❑ 91 NONE5 UNKNOWN <br /> 99 OTHER <br /> IV. PIPING INFORMATION IRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE p SUCTION p U 2 PRESSURE A U 3 GRAVITY A U 91 NONE p U 95 UNKNOWN A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALfEEA <br /> 3 LINED TRENCH A U 91 NONE p UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESS S3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE <br /> C. MATERIAL A U S ALUMINUM A U 6 CONCRET ] STEEL CLAD W/FRPA U 9 GALVANIZED STEEL p UU 9 NKNOWN 99 OTHER p U 8 100%METHANOL COMPATIBLE FRP <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P S VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S ] PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN <br /> P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF <br /> S1^ .T SUBSTANCE REMAINING IN 3- WAS TANK FILLED WITH <br /> W GALLONS INERT MATERIAL? VES [::] NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION <br /> # II III�AIG'ENCY# FACILITY ID M <br /> TANK ID N <br /> CURRENTLOC AGENCYFACILITYID# fba <br /> APPROV N ll O <br /> FI J PHONE k WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> 1 CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTA <br /> BY: <br /> FORM B(6-29-88) THIS FORM MUST BE ACCOMPANI Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS RENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />