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STATE OF CALIFORNI% WATER RESOURCES CONTRqWARD <br /> FORM 'B': UNDEPMROUND STORAGE TANK PROUPIAM �f ' <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. n <br /> MARK ONLY ❑ 1 NEW PERMIT3 RENEWALPERMIT oN Z <br /> ONE ITEM � �S CHANGE Of INFORMATION � 7 PERMANENTLY CLO c•` TANK 10 <br /> 2 INTERIM PERMIT 0 4 AMENDED PERMIT []6 TEMPORARY TANK CLOSURE <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: ❑B TANK REMOVED <br /> 21 S,.�uI h FARM TANK-YES E] NO J N <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN— <br /> SO SPECIFY N <br /> A. OWNERS TANK ID q I 'z . 1 I <br /> B. MANUFACTURED BY: N <br /> O� <br /> C. YEAR INSTALLED C.E? <br /> ( InkoD n D. TANK CAPACITY IN GALLONS: 5 <br /> If. TANK CONTENTS IF(A.1),IS 50 <br /> MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. [2'1 MOTOR VEHICLE;FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED I--7�,,,,EGEL <br /> 3 CHEMICAL PROD4 OIL . �I--y�F,/ LT ��80 EMPTY 95 UNKNOWN [ PRODUCT 4 GASAHOL El 5 JET FUEL 0 6 AVIATION GAS <br /> 5 HAZARDOUS 2 WASTE 7 METHANOL []99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICL,ENTER NAME OFHAZARDOUS SUBSTANORED&C.A.S.q <br /> ---------- C,A.S.q: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A. TYPE OF ❑ 1 DOUBLE WALLED 351NGLE WALLED WITH EXTERIOR LINER <br /> SYSTEM WALLED q SECONDARY CONTAINMENT ❑95 UNKNOWN <br /> __(C 99 OTHER <br /> B. TANK ❑ 1 STEEL/IRON 0 2 STAINLESS STEEL 3 FMERGLASS 4 STEEL CUD W/FIBEAGIASS REINFORCED PLASTIC <br /> MATERIAL ❑5 CONCRETE 6_POLYVINYL CHLORIDE 7 ALUMINUM <br /> 9 BRONZE 10 GALVANIZEb`STEEL UNKNOWN ❑W OEfl8 100% ETHANOL COMPATIBLE FRP <br /> C. INTERIOR 1!RUBBM LINED BE <br /> B. <br /> LINING 3EPDXY LINING 4PHENOUC LINING <br /> LINING ❑5 GLASS LINING 6 UNLINED <br /> 0 ISCINING MATERIAL COMPATIBLE WITH 10D%METHANOL? YES �-ryp �^�,,TMNOWN Ia <br /> D. CORROSION 4 1 POLYETHLENEWRAP L_j2 TAA OR ASPHALT 3 VINYL WRAP l�V <br /> 0 <br /> PROTECTION 5 CATHODIC PROTECTION 0 91 NONE 4 FIBERGLASS REINFORCED PUSTIO <br /> �'9S�UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATIO CLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U SUCTIO A U 2 PRESSURE <br /> A U 3 ORA"TV A U 91 NONE A U 9 U <br /> B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A A U 99 OTHER <br /> U .3 LINED TRENCH A U 91 NONE A UNKNOWN A U 99 OTHER <br /> A U i STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYLCHLORIDE PVC p <br /> C. MATERIAL A U 5 ALUMINUM A U 6 (PVC) U d FIBERGLASS PIPE A U 91 NONE <br /> A U 9 GALVANIZED STEEL A U' SUNKNOWN A U 7STEEL CLAD W/FRP A U 6100%METHANOL COMPATIBLE FRP <br /> 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 8 1 VISUAL CHECK © 2 INVENTORY gECONCILIATIO P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P ❑ n ;ROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S T PRESSURETESTING P 8 91 NONE P 8 95 UNKNOWN <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE OTHER <br /> 1.ESTIMATED DATE LAST USED <br /> 2. ESTIMATED QUANTITY <br /> —'- SUBSTANCE REMAINING OFIN 3.WAS TANK FILLED WITH <br /> I GALLONS INERT MATERIAL? YES [] NO <br /> THIS FORM HAS BEEN COMPLETED UNDER <br /> 77;7 PENAL OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> naPLICANTS NAME(PRINTED 8 SIGNATURE) <br /> DATE/ <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# <br /> g ❑� f T� FACILITY ID# TANK ID# <br /> CURRENTLLAOENCYF CIL17Y Ip/� APPROVED,B NAME c" -- <br /> NN GG (/ N � PNONEM WITX AREA CODE <br /> PERMITMOMBEW' <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK# PERMIT AMOUNT <br /> SURCHARGE AMT. FEE CODE <br /> \\ <br /> 1:1 1: BY: <br /> \uPORM B(6-29-a8) THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A „ ENT FORMA' NAS BEEN FILED <br /> DATA PROCESSING COPY <br />