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STATE OF CALIFORN�.: WATER RESOURCES CONTF' "BOARD <br /> FORM B': UNDERGROUND STORAGE TANK PROGRAM <br /> TANK PERMIT APPLICATION INFORMATION <br /> TANK COMP TE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY Eel"'NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED Lazi <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: goClFARM TANK-YES❑ NO <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 0 0 <br /> A. OWNERS TANK ID# B. MANUFACTURED BY'. <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: <br /> w <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. J' <br /> A. 1 MOTOR VEHICLE FUEL ❑Y PETROLEUM B G E:] 1 UNLEADED ❑ 2 LEADED IESEL N <br /> ❑ 3 CHEMICAL PRODUCT ❑6 OIL 1 PRODUCT ❑4 GASAHOL 5 JET FUEL ❑6 AVIATION GAS <br /> ❑ 5 HAZARDOUS ❑ 80 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&CAS.# #: /✓ <br /> MI. TANK CONSTRUCTION MARK ONE 1 M ONLY IN BOX A,B,C,A D <br /> DO WALLED F-13 SINGLE,(VALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN <br /> A TYPE OF El 1 <br /> SYSTEM L21fSINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER <br /> STEEL/IRON ❑ 2 STAINLESS STEEL F-�3FIBERGLASS 4STEEL CUD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ 8100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER <br /> C. INTERIOR <br /> F-] 1 RUBBER LINED 2 ALKYD G F-] 3 EPDXY LINING ❑4 PHENOLIC LINING <br /> LINING E] 5 CUBS LINING INEO � 95 UNKNOWN <br /> ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL9 ❑YES ❑ NO ❑ 99 OTHER <br /> D. CORROSION ❑ 1 POLYETHLENE WRAP5JR1AR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑ 95 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 U 99 OTHER <br /> B. CONSTRUCTION A 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 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE <br /> C. MATERIAL A U 5 ALUMINUM A U„¢ CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> ZED <br /> A U 9 GALVANISTEEL A AV; �'5 UNKNOWN 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 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P 6 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 US� /Y ) 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 /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION R AGENCY M FACILITY ID# TANK IDD# <br /> v <br /> CURRENT LOCAL AGENCY FACILITY I M U APPROVED BY NAIIE PHONE N WITH AREA CODE <br /> cry <br /> PERMIT NUMBER PERMIT APPROVAL DATE PER EXPIRATIONDATE <br /> ICHECK M PERMIT AMOUNT SURCHARGE AND. FEE CODE RECEIPT# BY: <br /> FORM B(3-7-SB) THIS FORM MUST BE ACCOMPAN A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A ENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />