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STATE OF CALIFORN(& WATER RESOURCES CONTBOARD <br /> FORM `B': UNDERGROUND STORAGE TANK PROGRAM <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 0 6 TEMPORARY TANK CLOSURE Ej B TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES E:j NO, <br /> I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY <br /> A. OWNERS TANK 10# U B. MANUFACTURED BY: v� <br /> C. YEAR INSTALLED WeD. TANK CAPACITY IN GALLONS: <br /> 11. TANK LATENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> IV <br /> A. 1 MOTOR VEHICLE FUEL ETROLEUM B. C. ❑ 1 UNLEADED DEO 3 DIESEL <br /> 3 CHEMICAL PRODUCT -amu 4 OIL 1 PRODUCT 4 GASAHOL 5 JET FUEL �6 AVIATION GAS <br /> 5 HAZARDOUS ❑ 60 EMPTY ❑ 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.N C.A.S.I7: <br /> .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,aD <br /> A. TYPE OF ❑ 1 DOUBLE WALLED E] 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEMNGLEWALLED 4 SECONDARY CONTAINMENT 99 OTHERivilMlEaLvIrif <br /> B. TANK / L/IRON 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/RBERGLASSREINFO LASTIC <br /> 5 CONCRETE 6 POLYVINYLCHLORIDE 7 ALUMINUM E] B 10AMMANOLCOMPATIBLEFRP JUL 14 <br /> MATERIAL ❑ 1988 <br /> 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> C. INTERIOR ❑ 1 RUBBERLINED 2 AU(YDUNING 3 EPDXY LINING 4 PHENOLICUNING ENVIROOMEWAL HEAD* <br /> PERMIT <br /> LINING ❑5 GLASS LINING ED E]95 UNKNOWN /SERVICE,$ <br /> IS LINING MATERIAL COMP LE�METHANOL? ❑YES E]NO 99 OTHER <br /> D. CORROSION ❑ 1 POLYETHLENEWRAP 2 TAR OR ASPHALT 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION �TH ODIC PROTECTION 91 NONE ❑95 UNKNOWN E] 99 OTHER <br /> IV. PIPING INFORMA ION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPEA U 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 U 5 UNKNOWN A U 99 OTHER <br /> A U 1 STEELPRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 6 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A 6995 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 PS 3 VADOSE WELLS 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURETESTING 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 3.WAS TANK FILLED WITH <br /> "9& SUBSTANCE REMAINING` GALLONS MATERIAL? E]YES ONO <br /> ICi <br /> THIS FORM HAS BEEN COMPLETED UNDERt.PEN{4LTY OF RJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE DATE <br /> APPLICANTS NAME <br /> �.� <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION N AGENCY k FACILITY ID M TANK ID R <br /> [3H] = = I je) l /jD I 4:51016 ,7:z <br /> CURRENT LOCAL AGENCY FACILITYjD M APPROVED BY NAME _ffo PHONE N WITH AREA CODE <br /> i <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHI PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT M BY: <br /> Is <br /> FORM B(3-7-M) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY `IJ <br />