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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'B': UNDERGROUND STORAGE TANK PROGRAM QO <br /> TANK TANK PERMIT APPLICATION INFORMATIONCOMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT5 CHANGE OF INFORMATION 10 <br /> ❑2 INTERIM PERMIT � <br /> ONE ITEM ❑ ❑ 7 PERMANENTLY CLOSEDTAN! <br /> jG <br /> ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE R TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: 574 N �pLe a^k. FARM TANK-YES❑ NO Ab <br /> I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY W <br /> A. OWNERS TANK ID# (✓"K),Ilkid B. MANUFACTURED BY: loop FG & Sot BS <br /> C. YEAR INSTALLED gF7q D. TANK CAPACITY IN GALLONS: SOO 01le.A-cr <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM O. <br /> A [�d I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. 1 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 ❑95 UNKNOWN �4❑J 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN REM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: <br /> I11. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D <br /> A.TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN <br /> SYSTEM &2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER <br /> ®1 STEELPRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK ❑5 CONCRETE ❑6 RXWNYLCHLORDE ❑ 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER <br /> C. INTERIOR F-11 RUBBER LINED ❑2 ALKID LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING <br /> LINING ❑ 5 GLASS LINING R976 UNLINED ❑95 UNKNOWN <br /> ❑ IS LINING MATERIAL COMPATIBLE WITH IDD%METHANOL? ❑YES ❑ NO ❑ 99 OTHER <br /> D. CORROSION ❑ 1 POLYETHLENE WRAP ®2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASRC <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 0 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 QP5 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 5ALUMINUM A U 6CONCRETE A U 7STEELCLADW/FRP A U 810096 METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZEDSTEEL A(IDI15 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 S VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P 5 5 PRECISION TESTIN P 7 PRESSURE TESTING P S 91 NONE P S 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 INERT MATERIAL? YES ❑ NO <br /> GALLONS <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE N� <br /> LOCAL AGENCY USE ONLY <br /> C-O�UNT(Y�# JURISDICTION# AGENCY# FACILITY ID# TANK ID# N� <br /> 1 -t I `91 l j V Ic <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME pp' PHONE#WITH AREA CODE <br /> GkIa CA 57 2 O <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> I`- <br /> CHECK# PERMITAMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: <br /> FoRMB(6-29as) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS CURRENT FORMA HASBEENFILED <br /> DATA PROCESSING COPY <br />