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STATE OF CALIFORNIA WATER RESOURCES CONTROI�DARD <br /> FORM `B': UNDERGROUND STORAGE TANK PROGRAM � w <br /> TANK PERMIT APPLICATION/INFORMATION <br /> TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWI G INFORMATION FOR EACH TANK. -- Z <br /> LC <br /> MARK ONLY ❑ I NEWPERMIT ❑3 RENEWALPERMIT t 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED W <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: S FARM TANK-VES NO ❑ N <br /> r <br /> I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: <br /> C YEAR INSTALLED D. TANK CAPACITY IN GALLONS: <br /> 11. TANK CONTENTS IF IRA),IS MARKED,COMPLETE ITEM C.IF IRA),IS NOT MARKED,COMPLETE ITEM D. <br /> A. ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL <br /> ❑3 CHEMICAL PRODUCT ❑4 OIL F-11 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS <br /> ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.M <br /> 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,AD <br /> A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN <br /> SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER <br /> ❑ 1 STEDURON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEELCLAOW/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> ❑ 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER <br /> C. INTERIOR ❑ 1 RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY LINING 4 PHENOLIC LINING <br /> LINING ❑5 GLASS LINING ❑6 UNLINED ❑ 95 UNKNOWN <br /> ❑ IS LINING MATERIAL COMPATIBLE WITH 100%MERIANOL? ❑YES ❑NO ❑99 OTHER <br /> D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TARORASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION ❑91 NONE ❑95 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 95 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 A U 95 UNKNOWN A U 99 OTHER <br /> A U I STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE <br /> C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 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 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS <br /> P 8 6 PRECISION TESTING P 8 7 PRESSURETESTING P 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> GALLONS <br /> SUBSTANCE REMAINING IN 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 /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> �T= 1 O <br /> CURRENT LOCAL AGENCY I.FT1' # APPROVEP BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATED/ PERMIT EXPIRATION DATE <br /> • / <br /> CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: <br /> UIP/ FORMB(6-29-88) THIS FORM MUST BE ACCOMPANIED BYA FACIUTY/SREAPPLICATIOK FORM`A',UNLESS A CURRENT FORMA• HASBEENFILED <br /> DATA PROCESSING COPY <br />