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'T" <br /> STATE OF CALIFORNS WATER RESOURCES CONTRIPOARD ••�,. :.�. <br /> F RM 'B': UNDERGROUND STORAGE TANK PR RAM <br /> TANG TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATIC}N I`ON EACH TANK. `" o, ,� <br /> MARK ONLY Q 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK 10 <br /> ONE ITEM El 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORAR`!TANK CLOSURE B TANK REMOVED ().�2 <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLEDs ��(r �� , yq r '�� d{ ' ,W/ FARM TANK-YES NO 1V <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY —4 <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: C" <br /> I! C. YEAR INSTALLED D, TANK CAPACITY IN GALLONS: <br /> IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. En-1-MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED Q 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT 4 OIL j. PRODUCT 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS 80 EMPTY ❑95 UNKNOWN 2 WASTE © 7 METHANOL El 99 OT14ER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.0 C.A.S.9: <br /> I11. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D <br /> A PIPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> I STEELPRON 2 STAINLESS STEEL ❑3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK F-1 5 CONCRETE 6 POLYVINYL CHLORIDE F-1 7 ALUMINUM B 100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> 9 BRONZE 10 GALVAVZED STEEL ❑95 UNKNOWN 99 OTHER <br /> C. INTERIOR I RUBBERLINED 2 ALKYD LINING F-13 EPDXYLINING ❑4 PHENOUCLINING <br /> LINING 5 GLASS LINING F-1 6 UNLINED [—]95 UNKNOWN <br /> IS LINING MATER{AL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 0 99 OTHER <br /> D.CORROSION © 1 POLYETHI_ENE WRAP ©2 TAR OR ASPHALT 3 VINYL WRAP E'4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN E]99 OTHER <br /> IV. PIPING INFORMATION 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 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 U 95 UNKNOWN A U 99 OTHER <br /> A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE 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 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 8 I VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS 0 9 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS <br /> P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P S 99 OTHER <br /> V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> I, ESTIMATED DATE LAST USED(MO/YR) 2, ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING 1N GALLONS INERT MATERIALS E]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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> Liz] El' I I I I I I El I I 16 [:--7- 1 /1 LL / <br /> CURRENT LOCAL AGENCY FACILITY ID S APPROVED BY NAME PHONE 4 WITH AREA CODE <br /> E <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK R PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT S BY: Cti <br /> 31,z-1; r r , <br /> FORM B(6-29-8B) THIS FORM MUST BE ACGOAIPANIED ACILITY151TE APPLICATION, FORM `A',UNLESS A C►,,,.-:NT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />