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STATE OF CALIFORNIA WATER RESOURCES CONTRO'-IOARD <br /> FORM 'B': / UNDEFWGROUND STORAGE TANK PROOO'i. AM ., •. <br /> TANK � TANK PERMIT APPLICATION INFORMATIONm,ry <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _. Z <br /> MARK ONLY 1 W PERMIT o 3 RENEWALPERMIT o 5 CHANGE OF INFORMATION1 0 <br /> 7 PERMANENTLY CLOS NK <br /> ONE ITEM 2 INTERIM PERMIT o 4 AMENDED PERMIT o 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED 0 <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: CA) <br /> M�I S FARM TANK-YES o NOEV CA) <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY C:) <br /> A. OWNERS TANK ID# as <br /> B. MANUFACTURED BY: � <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: <br /> II. TANK PONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL o 2 PETROLEUM B C. 1 UNLEADED o 2 LEADED 3 DIESEL <br /> 0 3 CHEMICAL PRODUCT o 4 OIL 1 PRODUCT o 4 GASAHOL o 5 JET FUEL 6 AVIATION GAS <br /> 0 5 HAZARDOUS 80 EMPTY o 95 UNKNOWN o 2 WASTE o 7 METHANOL o 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHI&E FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# CAS.IT <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A. TYPE OF o , WALLED 0 3 SINGLE WALLED WITH EXTERIOR LINER F-1 95 UNKNOWN <br /> SYSTEM E�r2 SINGLEWALLED o 4 SECONDARY CONTAINMENT o 99 OTHER <br /> F-] I STEEL/IRON 0 2 STAINLESS STEEL o 3 FIBERGLASS 0 4STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.MATERIAL 5 CONCRETE o 6 POLYVINYL CHLORIDE MINUM o 8 100%METHANOL COMPATIBLE FRP <br /> 0 9 BONZE o 10 GALVANIZED STEEL 95 UNKNOWN o 99 OTHER <br /> C. INTERIOR <br /> 1 RUBBER LINED -o 2 ALKYD LINING 0 3 EPDXY LINING o 4 ENOLIC LINING <br /> LINING o5 GLASS LINING o 6 UNLINED 95 NKNOWN <br /> F-1 SLIMING MATERIAL COMPATIBLEWITH 100%METHANOL? o YES o NO rTHER <br /> D. CORROSION ❑ I POLVETHLENE WRAP o 2 TAR OR ASPHALT o 3 LWRAP o 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION o 5 CATHODIC PROTECTION E] 91 NONE 95 UNKNOWN o 99 OTHER <br /> IV. PIPING INFORM GN CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A.SYSTEM TYPE A 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 1 STEELARON 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 /> 8 1VISUALCHECK Po 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> OP S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P 8 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? D YES o 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> Eff] lololl 6 doo <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED B NAME PHONE k WITH AREA CODE <br /> / PERMIT NUMBER PERMITAPPDATE 99 PERMIT EXPIRATION DATE <br /> L I <br /> CHECK If PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT. BY: C\ <br /> FORM B(6-29-BB) THIS FORM MUST BE ACCOMP A FACILITY/SITE APPLICATION, FORM 'A',UNLE%Igp0lIII FORM W HAS BEEN FILED <br /> DATA PROCESSING COPY <br />