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STATE OF CALIFORNA WATER RESOURCES CONTPOBOARD <br /> FORM 'B': UNDMIGROUND STORAGE TANK PRQGRAM of Ym, <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. o <br /> ro <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT t�j[-5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDEDPERMIT 6 TEMPORARY TANK CLOSURE B TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: <br /> L.c FARM TANK-YES NO z <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN SO SPECIFY <br /> 10 <br /> A. OWNERS TANKED# B. MANUFACTURED BY: <br /> C. YEAR INSTALLED ' <br /> D. TANK CAPACITY IN GALLONS <br /> II. TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. Sal MOTOR VEHICLE FUEL 2PETROLEUM B. C IV <br /> 1 UNLEADED 2 LEADED DIESEL <br /> 3 CHEMICAL PRODUCT 4 OIL ®-f PRODUCT 0 4 GASAHOL 5 JET FUEL AVIATION GAS <br /> 5 HAZARDOUS 80 EMPTY 95 UNKNOWN 2 WASTE D7METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# <br /> C.A.S.#: <br /> ■111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF ❑L�-�1 DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM �°SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> ®1 STEEL/IRON E]2 STAINLESS STEEL 0 3 FIBERGLASS <br /> B.TANK 0 5 CONCRETE q STEEL CLAD W/RBERGLASS REINFORCED PLASTIC <br /> MATERIAL EjfiPOLYWNYLCHLORL E]7ALUMINUM 610096 METHANOL COMPATIBLE FRP <br /> 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> C. INTERIOR ❑ I RUBBER LINED E]2 ALKYD UNING 3 EPDXY LINING E]{ 4 PHENOLIC LINING <br /> LINING [:] 5 GLASS LINING E]6 UNLINED UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? YES NO 99 OTHER <br /> D.CORROSION ❑ I POLYETHLENE WRAP 2 TARORASPHALT 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION �5 CATHODIC PROTECTION 91 NONE ER%UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION 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 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLWINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE <br /> C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP <br /> A U 9 GALVANIZED STEEL A6095 UNKNOWN A U 99 OTHER A U B 100%METHANOL COMPATIBLE FRP <br /> ------------- <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> /+ <br /> PS <br /> 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADDSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P 6 PRECIS <br /> 8ION TESTING P 8 7 PRESSURE TESTING P 8 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 <br /> SUBSTANCE REMAINING IN 3.WAS TANK FILLED WITH <br /> GALLONS INERT MATERIAL? YES E] 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) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# <br /> � TANK ID# <br /> oU <br /> CURRENT LOCAL AO N Y ACILITY ID# APPROVED BY NAME <br /> // / �/ PHONE#WITH AREA CODE <br /> PERMIT NUMBER (� I PERMIT APPROVAL DATE PERMIT EXPIR DA <br /> CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# <br /> BY: <br /> FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIE c A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A ENT FORMA' HAS BEEN FILED <br />