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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <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 /> 10 <br /> MARK ONLY ❑ 1 NEW PERMIT F-1 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 RMANENITLYC <br /> ONE ITEM ❑2 INTERIM PERMIT F-14 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED v <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: 5/ v'Q� FARM TANK-YES❑ NO CA) <br /> I. TANK DESCRIPTION COMPLETE LL ITEMS-IFU NOWN-SO SPECIFY w <br /> 00 <br /> A. OWNERS TANK ID# 0`l B. MANUFACTURED BY: w <br /> C. YEAR INSTALLED I q D. TANK CAPACITY IN GALLONS: do if <br /> 11. TANK96NTENTS IF(A.7),IS MARKED,COMPLETE ITEM C.IF(A.1), NOT MARKED OMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL <br /> 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS <br /> ❑5 HAZARDOUS ❑80 EMPTY E]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 8 C.A.S.# C.A.S.W <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,8,C,S D <br /> A TYPE OF BLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN <br /> SYSTEM NGLEWALLE ❑4 SECONDARY CONTAINMENT ❑99 OTHER <br /> 1 STEELPRON E]2 STAINLESS STEEL F-13 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK <br /> MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP <br /> � ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER <br /> C. INTERIOR ❑ 1 RUBBER LINE ❑2 ALKYD LINING ❑ 3 EPDXY LINING PHENOLIC LINING <br /> LINING ❑5 GLASS LINING ❑6 UNLINED 95 UNKNOWN <br /> ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER <br /> D.CORROSION ❑ I POLYETHLENEWRAP ❑2TAR OR ASPHALT ❑3 WRAP ❑4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION [:35 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑ 99 OTHER <br /> IV. PIPING INFORMA ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A.SYSTEM TYPE A U 11 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONEA 95 UNKNOWN A U 99 OTHER <br /> B.CONSTRUCTION A 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 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 RBERGLASSPIPE A U 91 NONE <br /> C.MATERIAL A U 5 ALUMINUM A6 CONCRETE A U 7 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A 5 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTIO22YSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> S 1 VISUAL CHECK S 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 TESTINGq S 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. NFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MOYYR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> 0 0 0HE c%1610 <br /> CURRENT LOCAL AGENCY FACILIT� APPROVED BY NAME W PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> FHMK# PERMITAMOUNT SURCHARGEAMT. FEE CODE I RECEIPT# BY: <br /> FORM B(6-29-88) THIS FORM MUST BE ACCOMPAN196BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />