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STATE OF CALIFORNO WATER RESOURCES CONTROBOARD ••' <br /> FORM B : UNDERGROUND STORAGE TANK PROGRAM _ <br /> TAN TANK PERMIT APPLICATION INFORMATION <br /> ' ` COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. '���` z <br /> f C] <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED r✓�� <br /> - W <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: a lc� FARM TANK-YES NO f\) <br /> d <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY (;) <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: 7-0 <br /> C. YEAR INSTALLED ri D. TANK CAPACITY IN GALLONS: <br /> II. TANK C TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPETE ITEM D. <br /> A Ek'lMOTOR VEHICLE FUEL Ej 2 PETROLEUM B. C EY1 UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT 4 OIL 1 PRODUCT ❑4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS BO EMPTY ❑ 95 UNKNOWN 2 WASTE Q 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.# C.A.S.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF ® I PUM WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ®95 UNKNOWN <br /> SYSTEM FA12"SINGLEWALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> D,rS-TEEL/IRCN 0 2 STAINLESS STEEL 3 FIBERGLASS ®4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK F-] 5 CONCRETE 6 POLYVINYLCHLORIDE F-] 7 ALUMINUM E]8 1 DO%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> Q 9 BRONZE 10 GALVANIZED STEEL [:] 95 UNKNOWN a 99 OTHER <br /> C. INTERIOR <br /> ® 1 RUBBER LINED N2UNED <br /> NO 3 EPDXY LINING E] 4 PHENOLIC LINING <br /> LINING 5 GLASSLINING 95 UNKNOWN <br /> IS UNING MATERIAL COMPATIBLE WITH 10096 METHANOL? YES [::] NO 99 OTHER <br /> D.CORROSION ® 1 POLYETHLENE WRAP B�91 <br /> T R ASPHALT 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION NONE 0 95 UNKNOWN Q 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A.SYSTEM TYPE A n 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 t!I 1 STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C.MATERIAL A 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZEDSTEEL A U 95 UNKNOWN A U 99 OTHER <br /> ------------ <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P S I VISUAL CHECK P 1 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> s 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 IMO/YR) 2- ESTIMATED QUANTITY OF3, WAS TANK FILLED WITH <br /> GALLONS <br /> REMAINING IN INERT MATERIAL? ®YES ❑ NO <br /> THIS FORM HAS SEEN COMPLETED CINDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME IPRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> Iola F 715- [ 71 0 1 J C3 7, <br /> CURRENT LOCAL AGENCY FACILITY 10# <br /> CURRENT BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER tY PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK 0 PERMIT AMOUNT SURD CIE AMT. FEE CODE RECEIP" 7 BY: _ <br /> FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />