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STATE OF CALL FO R N If WATER RESOURCES CONTRfOARDFORM 'B': UNDERGROUND STORAGE TANK PROAM <br /> TANK PERMIT APPLICATION INFORMATION '`' <br /> TANK COM LETS A SEPARATE FORM WITH THE:FOLLOWING INFORMATION FOR EACH TANK, ",aR"'` Z <br /> to <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CL K <br /> ONE ITEM 2 INTERIM PERMIT F-14 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVE o f <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: tWm / /� FARM TANK-YES❑ NO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY a) <br /> BY: �r f Q) <br /> A. OWNERS TANK ID# <br /> B. MANUFACTURED �" A <br /> C. YEAR INSTALLED D- TANK CAPACITY IN GALLONS: /l}U <br /> II. 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 PETROLEUM B. C. [:] 1 UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT LYJ 4 OILa 1 RODUCT El 4 GASAHOL 5 JET FUEL 6 AVIATIION GAS <br /> 5 HAZARDOUS B0 EMPTY 0 95 UNKNOWN V2 WASTE El 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 CONSTR CTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> 1 DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> A.TYPE OF <br /> SYSTEM 2 SINGLE WALLED 4 SECONDARY CCNTAINMENT 99 OTHER <br /> 1 STEELPRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM B 100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> 9 BRONZE [:] 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED 0 2 ALKYD LINING 3 EPDXY LINING 0 4 P ENOUC LINING <br /> C. INTERIOR <br /> F-15LINING GLASS LINING 1:16 UNLINED 5 ffUNKNOWN <br /> 0 IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 99 OTHER <br /> D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT 3 V LWRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION Q 5 CATHODIC PROTECTION [:]91 NONE 5 UNKNOWN 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 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 9j OTHER <br /> A U 1 STEELFIRON 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 Y 6 CONCRETE A U 7 STEEL CLAD WFRP A U 8 1 OD%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A 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 /> f P S I VISUAL CHECK 'P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELL P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> 17/ P S 6 PREDSION TESTING P S 7 PRESSURETESTING P S 91 NONE S 95 UNKNOWN P S 99 OTHER <br /> f/ 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 /> GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? 0 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 is SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> [a] I 1 1-1 L o I I / I 10 0 IT! <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE _ �s <br /> CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY:/ <br /> �(/ i <br /> (6-29-BB) THIS FORM MUST BE ACCOMPANIEd BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> 77z��{ DATA PROCESSING COPY <br />