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I ATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'B': UNDERGROUND STORAGE TANK PROGRAM o:.' <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. r <br /> MARK ONLY ❑ 1 NEW PERMIT 0 3 RENEWAL PERMIT � ��• z <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY c'D TANK G <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED:s Lkal ❑6 TEMPORARY TANK CLOSURE ®8 TANK REM <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNK OWN— M� �D FARM TANK-Y NO <br /> A. OWNERS TANK ID# SO SPECIFY � <br /> w 8. MANUFACTURED BY: Q <br /> C. YEAR INSTALLED N V <br /> D, TANK CAPACITY <br /> N GALLONS <br /> I1. TANK CONTENTS IF(A,1),IS MARKED,COMPLETE ITEM C.IF(A.1),S NOT MARKED.COMPLETE E ITEMM p. <br /> A ® 1 MOTOR VEHICLE FUEL 2 PETROLEUMB F� <br /> 3 CHEMICAL PRODUCT 4 OIL Q- 1 UNLEADED ]2 LEADED 3 DIESEL <br /> 5 HAZARDOUS 80 EMPTY 95 UNKNOWN � PRODUCT 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 2 WASTE <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF 117 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B,C,8 D C.A.S.#: <br /> A TYPE OF ❑1 DOUBLE WALED L_j 3 SINGLE WALLED WITH RTERIOR LINERI <br /> SYSTEM 2 SINGLE WAUED 65&UNKNOWN <br /> ❑4 SECONOARY CONTAINMENT F1 99 OTHER <br /> B.TANK Q I /IRON L_j 2 STAINLESSSTEEL 3 FIBERGLASS <br /> MATERIAL ❑5 CONCRETE 0 6 POLYVINYLCHLORIDE 7 ALUMINUM El <br /> 4 STEELCUNW/FIBEBGLASSgEINPONCEO FUSTIC <br /> 9 BRONZE � 6 IHANOL COMPATIBLE ARP <br /> 10 GALVANIZED STEEL C�*UNKNOWN %OTHER <br /> 1 RUBBERLINED <br /> C. INTERIOR ❑2 ALKYD UNING L_j 3 EPDXY LINING Ej 4 PHENOUC LINING <br /> LINING ❑5 GLASS LINING []6 UNLINED cE�54 UNKNOWN <br /> E] IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? El YES E]NO 99 OTHER <br /> D.CORROSION ❑1 POLYETHLENE WRAP E]2 TARORASPHALT [:]3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION E]5 CATHODIC PROTECTION E191 NONE 45:4M 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 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 A(ffl96 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FISERGLASSPIPE A U 91 NONE <br /> C.MATERIAL A U 5 ALUMINUM A/y,6 CONCRETE A U 7 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL N�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 S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS 6 4 ELECTRONIC MONITOR P 6 5 GROUNDWATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE B 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 /> SUBSTANCE REMAINING IN GALLONS I <br /> INERT MATERIAL? YES E] NO <br /> THIS FORM HASE OMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> LIWTS M (PRINTED S SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> HE = = lololtl7F?T--, ] c)ldo <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE R WITH AREA CODE <br /> 5/6-N)4 <br /> PERMIT NUMBER PERMIT APPR0 L DATE PERMIT EXPIRATION DATE <br /> N <br /> CHECK R PERMIT AMOUNT SURCHARGE AMT. FEE CODE B9B4TR BY: <br /> �V <br /> FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED Bl ACILR'YISRE APPLICATION, FORM'A',UNLESS ACU FORMA' HAS BEEN FILED 'I <br /> DATA PROCESSING COPY <br />