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STATE OF CALIFORNIA,.. WATER RESOURCES CONTROOARD <br /> FORM 'B': UNDERGROUND STORAGE TANK PROG'RAM <br /> TANK COMPLETEASNK PERMIT APPTE FORM WITH ILIICoATION ILLOWING NFORMATION <br /> EACH TANK. <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION o. <br /> ONE ITEM ED <br /> �/_7 PERMANENTLY CLOSED TANK <br /> 2 INTERIM PERMIT 04 AMENDED PERMIT D 6 TEMPORARY TANK CLOSURE U�TANK REMOVED 07 <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED:2WI N v l N <br /> KN FARM TANK•YES D NO 416 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS•IF UNKNOWN-SO SPECIFY __I <br /> A. OWNERSTANKID# B. MANUFACTURED BY: �A � <br /> C. YEARINSTALLED D. TANK CAPACITY IN GALLONS: <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> FIFNOT <br /> TOR VEHICLE FUEL � 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED 3 DIESEL <br /> MICAL PRODUCT D 4 OIL <br /> D i PRODUCT D 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> ARDOUS 0 80 EMPTY �95 UNKNOWN 2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> TOR VEHICLE FUEL,ENTER NAME OFUS SUBSTANCE STORED 8 C A.S.# <br /> C.A.B.#: <br /> 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A TYPE OF ❑ 1 DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER I�0 UNKNOWN <br /> SYSTEM E] 2 SINGLE WALLED 4 SECONDARY CONTAINMENT 0 99 OTHER <br /> 1 STEEURON 2 STAINLESS STEEL E] 3 FIBERGLASS D4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. MATERIAL F-] 5 CONCRETE 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM E:]8 100%METHANOL COMPATIBLE FRP <br /> 9 BRONZE 10 GALVANIZEDSTEEL C�d95 UNKNOWN E] 99 OTHER <br /> C.INTERIOR I RUBBER LINED 2 ALKYD LINING F-I 3 EPDXY LINING 4 PHENOLIC LINING <br /> LINING ❑5 GLASS LINING 6 UNLINED 4 9 UNKNOWN <br /> 0 ISUNING MATERIAL COMPATIBLEWITH 100%METHANOL' D YES D NO E] 99 OTHER <br /> D. CORROSION ❑ 1 POLYETHLENEWRAP 2 TAR OR ASPHALT Ej 3 VINYL WRAP F__j 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION [::] 5 CATHODIC PROTECTION 91 NONE b4z UNKNOWN El 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 95 UNKNOWN A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH A U 91 NONE p 5 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUM AU 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A 5 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 I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 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? E]YES 0 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 k TANK ID# <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> cG u 2g e /r <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK# PERMR AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: <br /> FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIY A FACILITYISITE APPLICATION, FORM 'A',UNLESS AVORENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />