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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'B': UNDERGROUND STORAGE TANK PROGRAM Qp <br /> TANK :- TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY ❑ I NEW PERMIT ❑ O RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM 2 INTERIM PERMIT I AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED d9 <br /> FACILITY/BITE NAME WHERE TANK IS INSTALLED: 9c;�Z- _ FARM TANK-YES❑ NO <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—BO SPECIFY <br /> A OWNERS TANK ID t B. MANUFACTURED BY: [� <br /> C,YEAR INSTALLED c{(C 0. TANK CAPACITY IN GALLONS: <br /> 02 J U <br /> 11. TANK CONTENTS IF(A.1).IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A 1 MOTOR VEHICLE FUEL ❑2 PETROLEUMB. C. I UNLEADED LEADED C]0 OIESEL <br /> ❑J CHEMICAL PRODUCT ❑1 OIL 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑ 8 AVIATION GAS <br /> ❑ 5 HAZARDOUS ❑80 EMPTY ❑9S UNKNOWN 2 WASTE ❑ 1 METHANOL ❑ 99 OTHER(DESCRIBE IN REM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED 6 C.A.S.t C.A.S.t: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B,C.A D <br /> A TYPE OF ❑ R WALLED 9 SINGLE WALLED WITH EXTERIOR LINER ❑95 mwcm <br /> SYSTEM 2 S WALLED 1 SECONDARYCONTAWMEM 99 OTHER <br /> I STEEUI DN ❑2 STAIMESSSTEEL ❑7 FIBERGLASS ❑1 STEEL CLAD W ROERGIASS REIMOflCED PLASTIC <br /> S.TANK ❑5 CONCFE7E <br /> YMATERIAL ❑6 POLYVINYL OILORtlDE ❑ 7 ALUMIRUM El 100%METHWOLCOWATWFFP <br /> ❑9 BRONZE ❑ 10 GALVANIZED STEEL [:].95 UNKNOWN ❑99 OTHER <br /> ❑ <br /> G INTERIOR <br /> 1 RJSBFALRE7 ❑2 LINING ❑7 EPDXY UNM ❑/PHEN XXUNING <br /> LINING ❑5 GUSS lIANO 8 LXl1NED ❑%UNONINTL <br /> ❑ B LINING MATERIAL OOWATMLE WITH IDD%WTHWKIL7 DYES E]NO ❑%OTHER <br /> D.CORROSION ❑ I POLYETFLFMEWMP ❑27/JI OgASPFUl1 ❑ 7 WRAP ❑ 1 FIBERGLASS REINFORCED FUSTIC <br /> PROTECTION ❑S GIHODC PIgTECTION ❑ 91 NONE _951:UNKNOWN ❑99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A 1 A U 2 PRESSURE A U S GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B.CONSTRUCTION A U A U 2 DOUBLE WALLED A U 7 LINED TRENCH A U 91 NONE A U %UNKNOWN A U 99 OTHER <br /> A U 1 EEL/ A U 2 STAINLESSSTEEL A U S POLYVINYLCHLORIDE(PVC) A U X FIBERGLASSPIPE A U 91 NONE <br /> C.MATERIAL A U 5 ALUMINUM A U C CONCRETE A U 7 STEEL CLAD W/FRP A U 9 IL%RIMETHANOL 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 /> P 1 ( VISUAL CHECK P t 2 INVENTORY RECONCILIATION P t 9 VADOSE WELLS P B I ELECTRONIC MONITOR P t 5 GflOUND WATER MONITORING WELLS <br /> P t. 9 PRECISION TESTING P t 7 PRESSURE TESFINO K t N NON P t 95 UNKNOWN P t 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> I.EST IMATED DATE LAST USED(MONA) 2. ESTIMATED QUANTITY OF S.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN OALLONB INERT MATERIAL? ❑YES <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 9 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY F rJURISDICTION I AGENCY I FACILITY ID 9 TANK ID <br /> EDL—L 1J 1. c ° 1 i I � -S 1 1 0 1 cc <br /> CURRENT LOCAL AGENCY FACILITY ID/ APPROVED BY NAME PHONE F WITH AREA CODE <br /> PlRYR NUYBlq PERMIT APPROVAL OAT[ PERU EXPIRATION DATE <br /> CHlCKI PERMITAMOUNT TURCHAROE AMT. FEE COD! �(ECEIPTI BY: <br /> r� <br />