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STATE OF CALIFORMIS WATER RESOURCES CONTRfOARDFORM `B': UNDERGROUND STORAGE TANK PROM - a^ <br /> TANK PERMIT APPLICATION INFORMATION <br /> TANK <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY PERMIT F-13 RENEWAL PERMET 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TA K <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> v � <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY .' <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: F �. es N <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS' d ® C� <br /> II. TANK C LATENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A• 1 MOTOR VEHICLE FUEL ETROLEUM B. C. 1 UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT 4 OILPRODUCT 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> L] 5 HAZARDOUS 0 80 EMPTY [:j95 UNKNOWN rFrf�l?Ill WASTE E:] 7 METHANOL A99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF �q <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# A,S V) C.A.S.0: <br /> III. TANK CONSTRCTION MARK ONE ITEM ONLY IN BOX A,B,C,A 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 /> STEEL/IRON 2 STAINLESS STEEL F-] 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK <br /> MATERIAL 5 CONCRETE ❑6 POLYVINYL CHLORIDE F-] 7 ALUMINUM E] 8 100%METHANOL COMPATIBLE FRP <br /> 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN D 99 OTHER <br /> C.INTERIOR <br /> 1 RUBBER LINED 2 ALKYD LINING F-] 3 EPDXY LINING E:]W95 <br /> HENOUC LINING <br /> LINING F-] 5 GLASS LINING �6 UNLINED UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES F-] NO [:] 99 OTHER <br /> D. CORROSION 0 1 POLYETHLENE WRAP 2 TAR OR ASPHALTNYL WRAP F-]4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION E] 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 U 1 SUCTION A U 2 PHESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B.CONSTRUCTION A U 1 SINGLE WALLED 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> A U 1 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 P6 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 S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 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 GALLONS INERT MATERIAL? 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 /> M:l I I Ll EI I I I ol 01116 ' �Eo = <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> ,e <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> \� CHECK 0 PERMIT AMOUNT SURCHARGE AMT. FEE CODE ECEIPT# BY: <br /> V <br /> FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIMY A FACILITY/SITE APPLICATION, FORM W,UNLESS A 4URRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />