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STATE OF CALIFORN14& WATER RESOURCES CONTROARD <br /> FORM `B': UNDE ROUND STORAGE TANK PROAM <br /> TANK TANK PERMIT APPLICATION INFORMATION ° <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWI G INFORMATION FOR EACH TANK. <br /> cg4ibaa �' <br /> ONLr NEW PERMIT n 3 RENEWAL PERMIT <br /> ITEM CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVEQQ� <br /> [FA;CILITY/SITEYINAME WHERE TANK IS INSTALLED: � y <br /> I8NZ, Syr FARM TANK-YES NO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK ID# 0 �t <br /> B. MANUFACTURED BYC�' <br /> C. YEAR INSTALLED <br /> D. TANK CAPACITY IN GALLONS: <br /> II. TANK CONTENTS IF(A.1 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM M <br /> A. 1 MOTOR VEHICLE FUEL 2 PETROLEUM g <br /> C. � 1 UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT Q 4 OIL P11--'PRODUCT 4 GASAHOL 5 FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS IJ 80 EMPTY Q 95 UNKNOWN 2 WASTE 7 METHANOL % OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# <br /> �Q C.A.S.#: <br /> iiiiiii <br /> Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF I DOUBLE WALLED Lj 3 SINGLE WALLED WITH EXTERIOR LINER Ej 95 UNKNOWN <br /> SYSTEM El 2 SINGLE WALLED 4 SECONDARY CONTAINMENT <br /> 99 OTHER <br /> B.TANK1 STEEL/RON 2 STAINLESS STEEL 0 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL ❑ 5 CONCRETE a 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 8 100%METHANOL COMPATIBLE FRP <br /> 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> C. INTERIOR ❑ 1 RUBBER LINED a 2 AL D LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> LINING 5 GLASS LINING LINEINED Q 95 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL, DYES F� NO 2�g9 OTHER UP, <br /> D. CORROSIONWl <br /> OLYETHLENE WRAP ❑2 TAR OR ASPHALT [:] 3 VINYL WHAP Q� 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTIONATHODIC PROTECTION 0 91 NONE F-195 UNKNOWN L_199 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A CV2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B. CONSTRUCTION A U 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 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYLCHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE <br /> A U STEEL CLAP WlFRP A U 3 i 00%METHANOL COMPATIBLE FRP <br /> 9 <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 /> P VISUAL CHECK 5 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S PRECISION TESTING P 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, ESTI ATED DATE LAST USED(MOIYR) 2, ES (MATED QUANTITY OF <br /> 3. WA TANK FILLED WITH <br /> ANCE REMAINING IN MATERIAL? <br /> v III, GALLONS (LYES NO <br /> THIS FORM HAS BEEN COMPLETE[}UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, 1S TRUE AND CORRECT. <br /> APPLICANT'S NAME)PRINTED&SIGNATURE) <br /> DATE <br /> LOCAL. AGENCY USE ONLY <br /> COUNTY* JURISDICTION# AGENCY# <br /> ljT = = FACILITY ID# TANK ID# <br /> CURRENT LOCAL AGENCY FA CITY ID# 10EK0 <br /> APPROVE":V <br /> PHONE#WITH AREA CODE <br /> PERMIT NUMBER A,({`� , � <br /> PERMIT AP VA E 1--m MIT EXPIRATION DATE <br /> .f <br /> pyCHECK# PERMIT AMOUNT Eta <br /> SURCHARGE AMT. <br /> FEE CODE RECEIPT# BY: <br /> FORM B(6-29-ee) THIS FORM MUST BE ACCOMPANI Y A FACILITYISITE APPLICATION, FORM 'A',UNLESS RENT FORM`A' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />