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STATE OF CALIFORNIab WATER RESOURCES CONTROARD <br /> FORM `B': UNDENGROUND STORAGE TANK PRO RAM <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY 1 NEW PERMIT L: 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CL <br /> ONE ITEM 2 INTERIM PERMIT F-] 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED 1 <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK YES NO y <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UN'KNOW'N-So SPECIFY <br /> A. OWNERS TANK ID# B. MANUFACTURED BY. rl <br /> G. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 7V <br /> 00 <br /> II. TANKCONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. Co <br /> A. 1 MOTOR VEHICLE FUEL F-] 2 PETROLEUMB. <br /> C. 1 UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT F-] 4 OIL i PRODUCT 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS m 80 EMPTY F-1 95 UNKNOWN 2 WASTE ❑ 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 /> x111, TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF [- 1 UBLE WALLED F-] 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED F-14 SECONDARY CONTAINMENT ❑99 OTHER <br /> 1 STEEUIRON F-�2 STAINLESSSTEEL ❑3 FIBERGLASS 4 STEEL CLAD WIFIBERGLASSREINFORCED PLASTIC <br /> B.TANK 5 CONCRETE F-� 6 POLYVINYLCHLORIDE F� 7 ALUMINUM 8 1004bMETHANOLCOMPATIBLE FRP <br /> MATERIAL <br /> 9 BRONZE 0 10 GALVANIZED STEEL [:]95 UNKNOWN D 99 OTHER <br /> ❑ 1 RUBBER LINED Ej 2 ALKYD LINING F-13 EPDXY LINING 0 ENOLIC LINING <br /> C. INTERIOR F-15 GLASS LINING El6 UNLINED �Vr95 <br /> NKNOWN <br /> LINING <br /> 13 LINING MATERIAL COMPATIBLE WITH 10046 METHANOL? YES [:] NO 99 OTHER <br /> D.CORROSION I POLYETHLENE WRAP 2 TAR OR ASPHALT 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE w 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 N U 1 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEELIIRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE( C) A U 4 FIBEHGLASS PIPE <br /> C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 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 /> FP) <br /> 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS <br /> P) <br /> 6 PRECISION TESTING S 7 PRESSURE TESTING 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? F-]YES Q NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,)S TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> FCuRRENTLOCAL <br /> JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> I Ll El I I I "IT-/ or o0 <br /> ENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE rr <br /> CHIECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: <br /> FORM B(3-7-a6) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM'A' HAS BEEN FILED �r � <br /> DATA PROCESSING COPY <br />