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STATE OF CALIFOR- } ^ WATER RESOURCES CON f' IOARD <br /> FORM `B': UNDnGROUND STORAGE TANK P9MRAM <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWALPERMIT 5 CHANGE OF INFORMATION `.�DTN <br /> ONE ITEM ❑ ❑ T PERMANENTLY D TANK <br /> 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE <br /> 8 TANK REMO D , <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: � <br /> Qp <br /> '�� FARM TANK-YES <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK ID p <br /> C. YEAR INSTALLED <br /> B. MANUFACTURED BY: <br /> D. TANK CAPACITY IN GALLONS Q <br /> II. TANK CONTENTS IF(A.1),IS MAgKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B <br /> C. � 1 UNLEADED 0 2 LEADED 7 3 DIESEL <br /> 3 CHEMICAL PRODUCT 0 4 OIL PRODUCT E]4 GASAHOL 0 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS Ej 80 EMPTY Ej 95 UNKNOWN 2 WASTE 0 7 METHANOL ED99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED A,C.A.S.# <br /> C.A.S.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D <br /> [TTANK <br /> OF 1 OgIBIE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> M SING IE WALIED r 4 SECONDARY CONTAINMENT <br /> 99 OTHER <br /> STEEL/IRON 26TAINLESS STEEL 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGUSS REINFORCED PLASTIC <br /> IAL 5 CONCRETE ❑6 POLYVINYLCHLORIDE 7 ALUMINUM 8100%METHANOL COMPATIBLE FHP <br /> 0 9 BRONZE 10 GALVANIZFDSTEEL 0 95 UNKNOWN 99 OTHER <br /> C. INTERIOR 1 RUBBER LINED j 2 AUPlD LINING 0 3 EPDXYLINING <br /> 4 PHENOLIC LINING <br /> LINING ❑5 GLASSLINING L:J N FD ❑ <br /> 95 UNKNOWN <br /> 0 IS LINING MATERIAL COMPATIBLE WITH 100%METHANOLP 0 YES Ej NO E]99 OTHER <br /> D. CORROSION [1 1 POLYETHLENEWRAP TAR OR ASPHALT 11 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION E]5 CATHODIC PROTECTION E]91 NONE �95 UNKNOWN 99 OTHER <br /> ED <br /> IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IFUNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE <br /> A U 3 GRAVITY A U 91 NONE A 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 5 UNKNOWN A U 99 OTHER <br /> A U 1 5fEEL/IgON 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 <br /> A U 9GALVANIZED STEEL A�95 UNKNOWN A U 7STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP <br /> A U W OTHER <br /> f�V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR $ FOR SECONDARY,A PpIMAgY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P g 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> IIV/IJ P S 6 PRECISION TESTING P S 7 PRESSURE TESTING <br /> 8 91 NONE P g 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MO/YR) <br /> N 2 ESTIMATED DUANTITY OF <br /> SUBSTANCE REMAINING IN 3. WAS TANK FILLED WITH <br /> 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 /> APPLICANT'S NAME(PRINTED 6 SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# <br /> FACILITY ID# <br /> n TANK ID# <br /> / ai5 <br /> CURRENT LOCAL AGENCY FACILITY ID# <br /> APPROVED BY NAPE <br /> Q � PHONE k WITH AREA CODE <br /> PERMIT NUMBER <br /> PERMIT APPROVAL DATE PER IT EXPIRATI DATE <br /> CHECK# PERMITAMOUNT SURCHARGE AMT. <br /> FEE CODE eeCE1PTR <br /> BY: <br /> FORMB(6-29-BB) THIS FORM MUST BE ACCOMPANIED BYA FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> ---- ---- - ___ -_ -_.._DATA PROCESSING COPY <br />