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STATE OF CALIFORNI WATER RESOURCESCONTR( 30ARD <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 ❑ i NEW PERMIT ❑ 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑77 PERMANENTLY CLOSED TANK 1 <br /> ONE ITEM F12 INTERIM PERMIT E]4 AMENDED PERMIT [:] 6 TEMPORARY TANK CLOSURE �'9 TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: 17671 E. /n� - <br /> (,t `--Tz FARM TANK-YES NO ❑ N <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY N <br /> A. OWNERS TANK ID# ' B. MANUFACTURED BY: K K A <br /> C YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 3 <br /> 11. TANK gONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTORVEHICLE <br /> PRODUCT <br /> 2 PETROLEUM R. 1 PRODUCT C ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS <br /> ID 1 UNLEADED [D 2 LEADED rg7�El- <br /> 3 CHEMICAL PRODUCT ❑4 OIL <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.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,A D <br /> A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER U?fUNKNOWN <br /> SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER <br /> ❑ 1 STEBUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK ❑5 CONCRETE ❑ <br /> MATERIAL 6 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP <br /> ❑9 BRONZE ❑10 GALVANIZED STEEL EDeUNKNOWN ❑99 OTHER <br /> C.INTERIOR <br /> ❑ I RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PH NOLICUNING <br /> LINING F-15 GLASS LINING F-16 UNLINED UNKNOWN <br /> ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER <br /> D. CORROSION ❑ i POLYETHIENE WRAP ❑ 2 TAR OR ASPHALT ❑3 WNY WRAP ❑4 RBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, 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 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 1 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 A4935 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 SE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS <br /> P 8 6 PRECISION TESTING P S I PgE55URE TESTING P S 9/ NON P B 95 UNKNOWN P 8 99 OTHER <br /> VI. INFORMATION ON TANK PERMANEN Y CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN OALLONB INERT MATERIAL? YES [D 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 /> CURRENT CAL AGENCY FACILITY ID# APPROVED Y NAME PHONE#WITH AREA CODE <br /> FRR I -7 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PE IT EXPIRATION DATE <br /> CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: <br /> FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />