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STATE OF CALIFORNI WATER RESOURCES CONTR( 90ARD <br /> FORM 4B': UNDERGROUND STORAGE TANK PROiURAM <br /> TANK TANK PERMIT APPLICATION INFORMATION y� <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. .� <br /> MARK ONLY ❑ 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 6 TANK REMOVED 02-, <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: S' FARM TANK-YES[�:] NO t <br /> N <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO PECIFr OJ <br /> A. OWNERS TANK IDR �� B. MANUFACTURED BY: c <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS <br /> II. TANK 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 B. C. 0 1 UNLEADED=#:: <br /> IESEL <br /> 3 CHEMICAL PRODUCT q OIL PRODUCT 4 GASAHOLIATION GAS <br /> E] 5 HAZARDOUS 80 EMPTY E]95 UNKNOWN 2 WASTE 7 METHANOL D,BELOW) <br /> D. IF <br /> NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.R <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF ❑1 DOUBLE WAUED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEELARON 2 STAINLESSSTEEL ❑3 FIBERGLASS E]4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK <br /> MATERIAL F-15 CONCRETE Ej 6 POLYVINYLCHLORIDE 7 ALUMINUM B 190%METHANOL COMPATIBLE FRP <br /> 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> C. INTERIOR IRUBBER LINED 2ALKYD LINING 3EPDXY LINING 4PHENDUC LINING <br /> LINING ❑5 GLASS LINING 6 UNLINED 95 UNKNOWN '.. <br /> IS LINING MATERIAL COMPATIBLE WITH I00%METHANOL? YES FNO 99 OTHER <br /> D. CORROSION ❑ 1 PDLYETHLENE WRAP ❑2 TAR OR ASPHALT 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC ' <br /> PROTECTION 5 CATHODIC PROTECTION E]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 91 NONE A 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 U 95 UNKNOWN A U 99 OTHER <br /> A U I STEEL/IRON A U2 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 A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U W OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS <br /> / P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 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 /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> � COOU�NT/Y R JURISDICTION R AGENCY R FACILITY ID R TANK ID R <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE M WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK PERMR AMOUNT SURCHARGEAMT. FEE CODE I RECEIPTR —m <br /> / <br /> FORM B(5-29-BR) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM'�p CURRENT FORMA' HAS BEEN FILED 7J/i <br /> DATA PROCESSING COPY <br />