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STATE OF CALIFORNI& WATER RESOURCES CONTRq&OARD <br /> FORM B': LAND GROUND STORAGE TANK PROGRAM o* ti <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING I ORMATION FOR EACH TANK. P <br /> ro <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION c4``op`" <br /> ONE ITEM �p INTERIM PERMIT ❑ 7 PERMANENTLY CLOSED TANK <br /> 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVEf Q <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED:' OS FARM TANK-YES NO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SO SPECIFY a <br /> A. OWNERS TANK ID# 75 B. MANUFACTURED BY: � <br /> C <br /> C. YEAR INSTALLEDIq 2, ! 73 <br /> D. TANK CAPACITY IN GALLONS: 6: 0� Q <br /> 11.rNOT <br /> TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. CA) <br /> R VEHICLE FUEL 2 PETROLEUM g W <br /> / C NLEADED 0 2 LEADED 3 DIESEL <br /> ICAL PRODUCT q OIL FL-�5� P/RODUCT 4 GASAHOL 0 5 JET FUEL 6 AVIATION GAS <br /> RDOUS 80 EMPN E] 95 UNKNOWN 2 WASTE 7 METHANOL 0 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> R VEHICLE FUEL,ENTER NAME OF SUBSTANCE STORED 8 C.A.S.# <br /> C.A.S.#: <br /> ,rill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B,C,&D <br /> A TYPE OF oI O ALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> B. TANK STEEL/IRON E]2 STAINLESSSTEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL ❑5 CONCRETE 0 6 POLYVINYLCHLORIDE 7 ALUMINUM 8 100%METHANOL COMPATIBLE FRP <br /> 0 9 BRONZE El 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> C.INTERIOR 1 RUBBER LINED ❑LINING Lj 3 EPDXY LINING 4 PHENOLIC LINING <br /> LINING E]5 GLASS LINING UNLINED 95 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ED NO D99 OTHER <br /> D.CORROSION ❑ 1 POLYETHLENEWRAP Ej 2 TAR OR ASPHALT 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION Ej 5 CATHODIC PROTECTION 1 NONE E] 95 UNKNOWN <br /> 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 2 PRESSURE A U 3 GRAVITY <br /> A U 99 OTHER <br /> B.CONSTRUCTIONA U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A ®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 <br /> C.MATERIAL A U 5 ALUMINUM A�Ur�6 CONCRETE A U 7 STEEL CLAD W/FRP <br /> A U 9 GALVANIZED STEEL A/V 195 UNKNOWN A U 99 OTHER A U B 100%METHANOL COMPATIBLE FRP <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 S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELLS <br /> P 6 PRECISION TESTING P S ]PRESSURE TESTING P S 91 <br /> ,ONE <br /> P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED 2. ESTIMATED QUANTITY OF <br /> SUBSTANCE REMAINING IN 3. WAS TANK EWITH <br /> GALLONS INERT MATERIAL' <br /> 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 8 SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> C1�OUITN'TYY# JURISDICTION# AGENCY# FACILIY IDN <br /> ZEE= <br /> T-AIlNK ID# <br /> (y V O <br /> [PERMIT <br /> RRENT LOCAL AGENCY FACILITY ID <br /> # APPROVED BY NA PHONE#WITH AREA CODE <br /> NUMBER PERMITAPPRO ALDATE p <br /> IT EKPIHA I' N DAT <br /> CHECK# PERMIT AMOUNT CHARGE AMT FEE CODE <br />\\`VN) RECEIPT# BY: <br /> SFORM B(3-7-88) THIS FORM MUST BE ACCOMPANIED B A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A UUMMENT FORMA HAS BEEN FILED <br /> DATA PROCESSING COPY <br />