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STATE OF CALIF010IA <br /> WATER RESOURCES C0O0L BOARD <br /> FORM `B': UNDERGROUND STORAGE TANK PROGRAM m a M1ti; <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. m <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT <br /> ONE ITEM 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> 0 2 INTERIM PERMIT 4 AMENDED PERMIT <br /> 6 TEMPORARY TANK CLOSURE �8 TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: <br /> V O FARM TANK-YES <br /> I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN— O ;V <br /> A. OWNERS TANK ID q SO SPECIFY <br /> ='! <br /> B. MANUFACTURED BY: Q7 <br /> C. YEAR INSTALLED <br /> D. TANK CAPACITY IN GALLONS: O <br /> II. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL 2 PETROLEUM <br /> 3 CHEMICAL PRODUCT � 4 OIL B C. ❑ 1 UNLEADED 2 LEADED DIESEL <br /> 1 LCT 4 GASAHOL 5 JET FUEL <br /> 5 HAZARDOUS 80 EMPTY g5 UNKNOWN ❑ 6 AVIATION GAB <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF ER� WASTE 7 METHANOL gg OTHER(DESCRIBE IN ITEM D,BELOW) <br /> HAZARDOUS <br /> IS STORED 8 C.A.S.4 A ). <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D /i CA S.q: <br /> A.TYPE OF ❑ 19GUBLE WALLED L_j 3 SINGLE WALLED WITH EXTERIOR LINER <br /> SYSTEM 2 SINGLE WALLED ❑95 UNKNOWN <br /> 4 SECONDARY CONTAINMENT 099 OTHER <br /> B.TANK I STEEUIRON D 2 STAINLESS STEEL 0 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 5 CONCRETE 0 6 POLYVINYLCHLORIDE D 7 ALUMINUM <br /> 9 BRONZE 010 GALVANIZED STEEL 1:199 OTHE 95 UNKNOWN ETHANOL COMPATIBLE FRP <br /> 99 OTHER <br /> C. INTERIOR I RUBBER LINED0 2 ALKYD LINING 3 EPDXY LINING D 4 PHENOLIC LINING <br /> LINING ❑5 GLASS LINING D 6 UNLINED <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES �NO gg OTHER <br /> ❑95 UNKNOWN <br /> � <br /> D.CORROSION ❑ I POLYETHLENE WRAP D 2 ARORASPHALT 0 3 VINYL WRAP <br /> PROTECTION [:]5 CATHODIC PROTECTION 91 NONE ❑4 FlBERGLASS REINFORCED PLASTIC <br /> 0 95 UNKNOWN 099 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 <br /> A U 3 GRAVITY A U 91 NONE A U <br /> B. CONSTRUCTION A U 1 SINGLE WALLED 5A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U WN A U 99 OTHER <br /> A U 1 STEEL/IRON NK OW A U 99 OTHER <br /> A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE <br /> A U 9 GALVANIZED STEEL A U 5 NKNOW A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> 9 <br /> 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 I VISUAL CHEC P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING <br /> 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 IAST USED(MO/YR) 2 ESTIMATED OUANTITV OF <br /> SUBSTANCE REMAINING IN 3. WAS TANK FILLED WITH <br /> GALLONS INERT MATERIAL? YES ONO <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(POINTED 8 SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION# AGENCY R <br /> FA TANK IDM <br /> 4 3 <br /> CURR LOC NCY FACILITY ID k <br /> APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE <br /> PERMIT EXPIRATION DATE <br /> CHECK M PERMIT AMOUNT SURCHARGE AMT. <br /> FEE CODE RECEIPTN <br /> BY: <br /> FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY CILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> DATA Donreceis,.. ........ <br />