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STATE 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. - s. <br /> :a <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT' 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: <br /> S �/'J FARM TANK-YES❑ NO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I C <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: ._#/k A4 <br /> 2A_ ^ (T <br /> C. YEAR INSTALLED - I r4 b D. TANK CAPACITY IN GALLONS: �T J <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. W <br /> A. i MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. 1 UNLEADED ❑2 LEADED ❑3 DIESEL <br /> ❑3 CHEMICAL PRODUCT ❑4 OIL [:] 1 PRODUCT ❑ < GASOHOL ❑5 JET FUEL ❑fi AVIATION GAS <br /> ❑5 HAZARDOUS ❑60 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 /> All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER <br /> 1 STEEL/IRON 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/RBERGIASS REINFORCED PLASTIC <br /> B.TANK 5 CONCRETE6 POLYVINYLCHLORIDE 7 ALUMINUM B 100%METHANOL COMPATIBLE FRP <br /> MATERIAL ❑ ❑ ❑ <br /> ❑9 BRONZE 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER <br /> C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC UNING <br /> LINING ❑5 GLASS UNING ❑ 6 UNLINED 995 UNKNOWN <br /> ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO OTHER <br /> D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT D VINYL WRAP [:]4 FIBERGLASS REINFORCED PUS RC <br /> PROTECTION 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN E-]99 OTHER <br /> IV. PIPING INFORMA ON 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 A99 OTHER <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 5 UNKNOWN A U 99 OTHER <br /> A 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE <br /> C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 9 100%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 /> S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MOMTORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING S 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 /> NSUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ NO <br /> THIS FORM HAS tIEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> AP CANT'S NAME(PRINTED&SIGNATURE) DATE <br /> 7 <br /> LOCAL AGtWdY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> 00 $ o Cil <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> M it, L f iwb I LJ fl-5 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK# PERMIT AMOUNT _ SURCHARGE ANY. FEE CODE RECEIPT# BY: <br /> FORM B(3-7-66) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM`A',UNL A CURRENT FORMA' HAS BEEN FILED <br /> ')ATA PROCESSING COPY <br />