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' ;.. '.N '4 'Cr.�,g .:3 ?'S'•'rt'k. .. -m.,�j!-+�IE,,�^CA',.f r"�^J74•'6'�'.:�""R, <br /> STATE OF CALIFORNIA- WATER RESOURCES CONTROSPARD <br /> FORM `B': UNDE ROUND STORAGE TANK PROGRAM <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. o °P <br /> MARK ONLY 1 NEW PERMIT F-] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION _E'57 PERMANENTLY CLOSEDTANK <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: 51 I FARM TANK-YES❑ NO-�' <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: <br /> C. YEAR INSTALLED UPK 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. <br /> A. 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. 1 UNLEADED 2 LEADED 3 DIESEL , 4 <br /> ❑3 CHEMICAL PRODUCT �4 OIL � 1 PRODUCT ❑ 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> El 5 HAZARDOUS 0 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 z <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# uj Q L C.A.S.#: 03 s j <br /> x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF 1 DOUBLE WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM Ji r 2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> I 1 STEEL/IRON 2 STAINLESS STEEL F-] 3 FIBERGLASS 4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK F-] 5 CONCRETE 6 POLYVINYLCHLORIDE F-1 7 ALUMINUM F-]8 100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> 9 BRONZE 10 GALVANIZED STEEL ❑95 UNKNOWN 99 OTHER <br /> C. INTERIOR 1 RUBBER LINED F-12 ALKYD LINING ❑3 EPDXY LINING 4 PHENOLIC LINING <br /> LINING ❑ 5 GLASS LINING 5T6 UNLINED Ej 95 UNKNOWN <br /> E] IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? El YES [-] NO [::] 99 OTHER <br /> D.CORROSION ❑ 1 POLYETHLENE WRAP E 2 TAR OR ASPHALT F-]3 VINYL WRAP E] 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION [::] 5 CATHODIC PROTECTION E]91 NONE 5RT95 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 n 3 GRAVITY A U 99 OTHER <br /> B.CONSTRUCTION A O1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> A@ 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE <br /> C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> 1 A U 9 GALVANIZED STEEL A U 95 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 S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE ©S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATEP 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTYY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> / Lotliltflolol <br /> [PERMIT <br /> RENT LOCAL AGENCY FACILITY ID# APP OVE BY NAM PHONE#WITH AREA CODE <br /> Li---, <br /> NUMBER PERMIT APPROVAL D TE PERMIT EXPIRATION DATE <br /> CK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: <br /> —FORM ts(3 7-88)----THIS FORM MUST BE ACCOMPANI . A FACILITY/SITE APPLICATION, FORM`A',UNLES RENT_FORMX HAS BEEN FILED <br /> DATA PROCESSING COPY <br />