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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD '`'..... <br /> �ea J <br /> FOR),`M 'B': UNDERGROUND STORAGE TANK PROGRAM :? 4 - . :a <br /> TANK TANK PERMIT APPLICATION INFORMATION u I <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK- E <br /> MARK ONLY ❑ 1 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 TANK REMOVED �Cl' i <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: -�Y. [� / ? /+ FARM TANK-YES❑ NO <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY i <br /> A. OWNERS TAN!(ID# B. MANUFACTURED BY: j <br /> C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 5 i <br /> 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. MOTOR VEHICLE FUEL 2 PETROLEUMVI <br /> C. 1 UNLEADED 2 LEADED 3 DIESEL <br /> l <br /> 3 CHEMICAL PRODUCT 4 OIL RODUCT <br /> 4 GASAHOL 5 JET FUEL 6 AVIATION GAS ; <br /> 5 HAZARDOUS 80 EMPTY D 95 UNKNOWN 2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> I <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.ON/4 <br /> 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,&D <br /> A TYPE OF E] 1 BLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM SINGLE WALLED ❑<SECONDARY CONTAINMENT 99 OTHER 1 <br /> 1 STEEUIRON 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC } <br /> B.TANK S CONCRETE 6 POLYVINYL CHLORIDE �7 ALUMINUM B 100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> ED9 BRONZE 10 GALVANIZED STEEL E] 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR Ej5 GLASS LINING 6 UNLINED 95 UNKNOWN <br /> LINING <br /> ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? �YES ❑ NO 99 OTHER <br /> D.CORROSION ❑ 1 POLYETHLENEWRAP '0 2 TAR OR ASPHALT 3 VINYLVlRAP 4 FIBERGLASSREINFORCEOPLASTIC <br /> PROTECTION [7]5 CATHODIC PROTECTION F] ' 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 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A V 99 OTHER <br /> 1 <br /> A U 1 STEEL/IRON 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 V B 100%METHANOL COMPATIBLE FRP <br /> 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 I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S..4 ELECTRONIC MONITOR P S 5 GROUTED WATER MONITORING WELLS <br /> P S 6 PRECISION TESTWG P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 4TjaER��-^ <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MO/(R) 2. ESTIMATED QUANTITY OF 3.WAS TANK + -'O0 <br /> GALLONS <br /> SUBSTANCE REMAINING IN INERT MATERIAL? br'YES �1i!N <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# JURISDICTION# AGENCY# FACILITY ID# TANK ID N <br /> 6 1 a _Tao D6 <br /> [PERMIT <br /> RENT LOCA AGENCY FACILITY ID N APPROVED BY NAM PHONE 11 WITH AREA CODE <br /> �� a 4 © ,� <br /> NUMBER PERMIT APPROVAL DA7 PERMIT E%PfRATION DATECK R PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT a <br /> RM MUST BE ACCOMPANteD BY A FACILITYISITE APPLICATION, FORM `A',UNLESS A RRENT FORMA' HAS BEEN FILED r <br /> `FORMnl6-2e-»1'SFi1SFA yft�l nATA PRIOC:ESSING COPY <br />