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STATE OF CALIFORNIAM WATER RESOURCESCONTROARD <br /> FORM 'B': UNDE GROUND STORAGE TANK PRO AM =b <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOW10 INFORMATION FOR EACH TANK. - »� <br /> MARK ONLY ❑ 1 NEWPERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: 9.2S3 S FARM TANK-YES NO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY <br /> A. OWNERS TANK IDN B. MANUFACTURED BY: <br /> C.YEAR INSTALLED D.TANK CAPACITY IN GALLONS: SQA <br /> IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A7),IS NOT MARKED,COMPLETE ITEM D <br /> A. ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUMB. C. ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL <br /> F-]3 CHEMICAL PRODUCT D4' / 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS <br /> ❑ 5 HAZARDOUS ��dO 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.# CAS.N: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN OK A B,C, D <br /> A TYPE OF ❑I DOUBIEWAUED ❑3 SINGLE WALLED NTH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑%OTHER <br /> ❑ 1 STEEUIRON ❑2 STAINLESS STEEL WALUMINUM <br /> BERGNSS ❑4 STEEL GLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑B 100%METHANOLCOMPATIBLEFRP <br /> MATERIAL <br /> ❑9 BRONZE ❑ 10 GALVANIZED STEELUNKNOWN ❑%OTHER <br /> F-11 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING PHENOLICUNING <br /> C. INTERIOR <br /> LINING F-15 GLASS LINING ❑ 6 UNUNED %UNKNOWN <br /> ❑ IS LINING MATERIAL COMPATIBLE NTH Ion METHANOL? ❑YES ❑ NO ❑99 OTHER <br /> D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALTINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION E)91 NONE %UNKNOWN ❑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 U 2 PRESSURE A U 3 GRAVITY A U91 NONE 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 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEELMRON 6AU <br /> STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U BERGLASS PIPE A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUMCONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEELUNKNOWN 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 5 1 VISUALCHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 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 DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED A SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID N <br /> CURRENTL AGENCY FACILITY ID# _ APPROVED BY NAME PHONE k WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK# PERMIT AMOUNT SURCHAR EAMT. FEE CODE RECEIPT# BY <br /> C <br /> FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY7SITE APPLICATION, FORM 'A',UNLESS A CURRENT M'A' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />