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STATE OF CALIFORNI16 WATER RESOURCES CONTR OARD <br /> FORM `B': UNDERGROUND STORAGE TANK PROGRAM Go <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWALPERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY C SEDT I O <br /> ONE ITEM ❑2 INTERIM PERMIT E]4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE Ej 8 TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY FC�L <br /> A. OWNERS TANK ID# © B. MANUFACTURED BY: (� <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: AO& <br /> 11. TANK CONTENTS IF(AL1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL F-1 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT q OIL 21 1 PRODUCT E]4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS 80 EMPTY E 95 UNKNOWN 2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM 0,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED d C.A.S.# 4 114A C.A.S#: rQ <br /> III. TANK CONSTRUCTION MARK ONE ITEM ON YIN BOX A,B,C,8 D <br /> A. TYPE OF ❑ 1 DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN <br /> SYSTEM r�r2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> B. TANK 1 STEEUIRON 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 0 6 CONCRETE ❑6 POLYVINYLCHLORIDE 7 ALUMINUM E] 810096 METHANOL COMPATIBLE FRP <br /> Ej 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> C. INTERIOR 1RUBBER LINED 2ALKYD LINING 3EFOXYLINING 4PHENOUCUNING <br /> LINING ❑5 GLASS LINING 6 UNLINED 95 UNKNOWN <br /> )SLIMING MATERIAL COMPATIBLE WITH 100%METHANOL9 DYES E:jNO HER <br /> D. CORROSION ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT D <br /> J'3MLWRAP q FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION Ej 91 NONE E795 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMA N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A CONSTRUCTION <br /> A 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 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 I 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 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A F UINS UNKNOWN A U 99 OTHER <br /> . LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P 1 =ION <br /> P 5 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P B PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DAT LAST USED(MO/YR) 2. ESTIMATED OUA ITV OF 3. WAS TANK R ED WITH <br /> ✓(/ A SUBSTANCE R A ING IN GALLONS INERT L7 El YES � NO <br /> W <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF P RJURY,AND TO THE BEST OF MY KNOWLED E,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED S SIGNATURE) E <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# <br /> TANK ID# <br /> a1 � ED � � <br /> CURRENT L CAL,AQgNCY FACILITY ID 0 APP VED BY NAME <br /> '/\ �'j -/ PHONE WITH AREA CODE <br /> PERMIT NUMBER G/ PERMIT APPROVAL DATE PER TEXPIRATION DATE <br /> CHECKN PERMIT AMOUNT RCHARGE AMT. FEE CODERE IPT# <br /> BY: <br /> FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITYYSITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />