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STATE OF CALIFORNIt WATER RESOURCES CONTRO' 90ARD "`•�'`'F <br /> FORM `B': UNDE►,GROUND STORAGE TANK PRO!"AM ® <br /> TANKTANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z <br /> 10 I <br /> 1 NEW PERMIT <br /> MARK ONLY ❑ 3 RENEWALPERMIT CHANGE OF INFORMATION 7 PERMANENTLY NK <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVEDI� <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: D d D FARM TANK-YES❑ NO (� <br /> W <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY O <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: <br /> Vki <br /> C. YEARINSTALLED U D. TANK CAPACITY IN GALLONS'. Q V <br /> IL TANK PONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL O 2 PETROLEUMC. ❑ 1 UNLEADED L] 2 LEADED D!3,.gJESEL <br /> 3 CHEMICAL PRODUCT F� B.4 OIL /1PRODUCT 1:1 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS [-] 80 EMPTY D 95 UNKNOWN 2 WASTE E]7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.k: <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.a <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,A D <br /> OWN <br /> A.TYPE OF F-1 I DOUBLE WALLED F-1 3 SINGLE WALLED WITH <br /> SYSTEMSINGLE WALLED 4SCONDARY CONTAINMENTIOR LINER 995 OTHER <br /> 1 STEBUIRON 2 STAINLESSSTEEL F-�3 FIBERGLASS F-1 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK 5 CONCRETE 6 POLYVINYLCHLORIDE [:] T INUM 8100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> .. 1 RUBBER UNC 2 ALKYD LINING 3 EPDXY LINING n 4 PPI NOLIC LINING <br /> C. INTERIOR <br /> LINING 5 GLASS LINING 6 UNLINED L�vJ/95 UNKNOWN <br /> LINI <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑NO ❑99 OTHER <br /> D. CORROSION ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT 3 V WLWRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 91 NONE E14 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 5 UNKNOWN A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE 5CU25 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P S 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS <br /> L/• P S 6 PRECISION TESTING P 9 7 PRESSURE TE STING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> L ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN "LLONS INERT MATERIAL? YES [:]NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION R AGENCY B FACILITY ID A TANK ID B <br /> oo � v] rT I oa <br /> CURRENT LOCAL AGENCY FACILITY ID A APPROVED BY N E PHONE R WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> 12_ <br /> 24, <br /> CHECK K PERMIT AMOUNT -'RCHARGE AMT. FEE CODE RECEIPT N BY: <br /> V FORM B I6-29-eel THIS FORM MUST BE ACCOMPANIED BY A FACILITYYSITE APPLICATION, FORM 'A',UNLESS A CU RENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />