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STATE OF CALIFORN6 WATER RESOURCES CONTFOBOARD <br /> FORM `B': UNDERGROUND STORAGE TANK PROGRAM <br /> TANKTANK PERMIT APPLICATION INFORMATION <br /> MPLETE A SEPARATE FORM WITH THE FOLLOWIn INFORMATION FOR EACH TANK. - Pa <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLO <br /> ONE ITEM r-1 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: Tao H,, ,+C FARM TANK-YES Ej NO/ <br /> .p <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK IDM B. MANUFACTURED BY: W <br /> C. YEAR INSTALLED ilk D. TANK CAPACITY IN GALLONS: Cl <br /> n <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. ❑ 1 MOTOR VEHICLE FUEL Ej 2 PETROLEUM B. C. 1 UNLEADED ❑ 2LFUEL <br /> E] 3 DIESEL <br /> 3 CHEMICAL PRODUCT 4 OIL <br /> 1 PRODUCT 4 GASAHOL 5 6 AVIATION GAS <br /> 5 HAZARDOUS 0 80 EMPTY ❑95 UNKNOWN 2 WASTE 7 METHANOL 9RIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED 8 C.A.S.M C.A.S.p: <br /> 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN SOX A,B,C,A O <br /> A TYPE OF ❑ I DOUBLEWALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLEWALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEEL/IRON 2 STAINLESS STEEL 0 3 FIBERGLASS E]4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK 5 CONCRETE 6 POLYVINYLCHLORIDE F-1 7 ALUMINUM B 100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER <br /> C. INTERIOR 1 RUNERUNED 2 ALKYD LINING F-13 EPDXY LINING 4 PHENOLIC LINING <br /> LINING ❑ 5 GLASS LINING 6 UNLINED 95 UNKNOWN <br /> ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 99 OTHER <br /> D. CORROSION ❑ I POLYETHLENE WRAP [:]2 TAR OR ASPHALT F_�3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION E] 91 NONE E:] 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 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 STEEL/IRON 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 B 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 /> P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 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 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? YES 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 6 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION M AGENCY N FACILITY 10 M TANK ID W <br /> CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAME PHONE Y WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATEPERMIT EXPIRATION DATE <br /> Z <br /> CHECK Y PERYIT AMOUNT SURCHARGE AMT. FEE CODE ECEIPT• BY; <br /> FORM B(6-29-Bfi) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A CURRENT FORMA' HAS BEEN FILEDLED <br /> DATA PROCESSING COPY <br />