Laserfiche WebLink
'STATE OF CALIFORN°`) WATER RESOURCES CONTF' BOARD <br /> .FORM 'B': UNDERGROUND STORAGE TANK PROGRAM <br /> TANK TANK PERMIT APPLICATI N INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLO ING FORMATION FOR EACH TANK. G <br /> I[ <br /> MARK ONLY f ❑ I NEW PERMIT 3 RENEWAL PERMIT 3115'CHANGE OF INFORMATION 7 PERMANENTLY MO [E:: <br /> ONE ITEM E12 INTERIM PERMIT E14 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE Ej B TANK REMOVEDFACILITY/SITE NAME WHERE TANK IS INSTALLED: (�QS FARM TANK-YE5 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIIY <br /> A. OWNERS TANK IDN B. MANUFACTURED BY: <br /> C.YEAR INSTALLED 1,1-- D. TANK CAPACITY IN GALLONS: la <br /> i <br /> II. TANK PONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS YOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM Bjol-' RODUCT <br /> C. 1 UNLEADED 2 LEADED •M116 <br /> 3 CHEMICAL PRODUCT ❑ 4 OIL 4 GASAHOL 5 JET FUEL D 6 AVIATION GAS <br /> E15 HAZARDOUS ❑ 86 EMPTY 0 95 UNKNOWN 2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM 0,BELOW) <br /> D. IF NOT MOTOR VEHICLE.FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.N C.A.S.N: <br /> I <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D <br /> A-TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER E]95 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEELIIRON 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD WIFISERGLASSREINFORCED PLASTIC <br /> B.TANK ❑ 5 CONCRETE 6 POLYVINYL CHLOR4DE 7 ALUMINUM 8 10096 METHANOL COMPATIBLE FRP <br /> MtATERUtL. <br /> 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> C. INTERIOR RUBBER UNED 2 ALKYD LINING 3 EPDXY UNINC 4 PHENOLIC LINING <br /> LINING ❑ 5 GLASS LINING 6 UNLINED 95 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES t 0 99 OTHER <br /> D.CORROSION ❑ 1 POLYETHLENE WRAP 2 TAA 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 UNDERGRO JND,BOTH IF APPLICABLE <br /> A.SYSTEM)TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 C RAVITY 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 LINEDTRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEELARON 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 U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 3THER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECO qUARY.A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> i <br /> P B I VISUALCHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P B 91 NONE S 95 UNKNOWN P S 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 <br /> A1Oµ8 INERT MATERIAL? DYES D 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 g <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION 11 AGENCY K FACILITY ID 0 YANK ID# <br /> = a 1 & I <br /> CURRENT LOCAL AGENCY CILITY ID 0 APPROVED Y NAME PHONE#WITH AREA CODE <br /> U Z <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE p' �/J <br /> O t^' I <br /> CHECK II PERMIT AMOUNT SURCHARGE AMT. FEE CODE ECEIPT 9 BY: <br /> i <br /> FORM B(e-29.86) THIS FORM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br />