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STATE OF CALIFORN WATER RESOURCES CONTR OARD <br />FORM `B': UNDEfGR ND <br />OU STORAGE TANK PRQAM <br />TANK TANK PERMIT APPLICATION INFORMATION <br />COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br />MARK ONLY NEW PERMIT F-] 3 RENEWAL PERMIT F-1 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOS <br />ONE ITEM 2 INTERIM PERMIT r-1 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMO <br />FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK - YES ❑ NO <br />I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY <br />A. OWNERS TANK ID # B. MANUFACTURED BY: K <br />C. YEAR INSTALLED ' Fs8 D. TANK CAPACITY IN GALLONS: �'[� <br />II. TANK CONTENTS IF (A.1). IS MARKED. COMPLETE ITEM C. IF (A.11. IS NOT MARKED- COMPLETE ITEM e_ <br />A. F-] 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM <br />B.C. <br />1 UNLEADED 2 LEADED 3 DIESEL <br />3 CHEMICAL PRODUCT CK4 OIL <br />X1'1 PRODUCT <br />� 4 GASAHOL � 5 JET FUEL E]6 AVIATION GAS <br />1:1� 5 HAZARDOUS 0 80 EMPTY 95 UNKNOWN <br />0 2 WASTE <br />7 METHANOL �99 OTHER (DESCRIBE IN ITEM D, BELOW) <br />D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF <br />HAZARDOUS SUBSTANCE STORED & C.A.S. # �eAeL- Q L, C.A.S. #: <br />x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D <br />A. TYPE OF <br />❑ 1 DOUBLE WALLED <br />F-1 3 SINGLE WALLED WITH EXTERIOR LINER <br />F� 95 UNKNOWN <br />SYSTEM <br />X2 SINGLE WALLED <br />[::] 4 SECONDARY CONTAINMENT <br />1:1 99 OTHER <br />A <br />1 STEEL/IRON <br />2 STAINLESS STEEL <br />� 3 FIBERGLASS <br />4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br />B. TANK <br />MATERIAL <br />F-15 CONCRETE <br />6 POLYVINYL CHLORIDE <br />F-]7 ALUMINUM <br />8 100% METHANOL COMPATIBLE FRP <br />A <br />0 9 BRONZE <br />Ej 10 GALVANIZED STEEL <br />;�0195 UNKNOWN <br />99 OTHER <br />U 5 ALUMINUM A U <br />i RUBBER LINED <br />1:12 ALKYD LINING <br />� 3 EPDXY LINING <br />4 PHENOLIC LINING <br />C. INTERIOR <br />LINING <br />❑ 5 GLASS LINING <br />1:1 6 UNLINED <br />95 UNKNOWN <br />kT95 UNKNOWN <br />U 99 OTHER <br />IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? <br />YES [::] NO <br />Ej 99 OTHER <br />D. CORROSION <br />❑ 1 POLYETHLENE WRAP <br />2 TAR OR ASPHALT <br />F-1 3 VINYL WRAP <br />F-1 4 FIBERGLASS REINFORCED PLASTIC <br />PROTECTION <br />[:] 5 CATHODIC PROTECTION <br />91 NONE <br />D?95 UNKNOWN <br />[:] 99 OTHER <br />IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND. BOTH IF APPLICABLE <br />A. SYSTEM TYPE <br />AU <br />1 SUCTION A U <br />2 PRESSURE <br />A <br />U 3 GRAVITY A U <br />99 OTHER <br />B. CONSTRUCTION <br />A <br />U 1 SINGLE WALLED A U <br />2 DOUBLE WALLED <br />A <br />U 3 LINED TRENCH A (D <br />95 UNKNOWN A U 99 OTHER <br />PERMIT AMOUNT <br />A <br />U 1 STEEL/IRON A U <br />2 STAINLESS STEEL <br />A <br />U 3 POLYVINYL CHLORIDE (PVC) <br />A U 4 FIBERGLASS PIPE <br />C. MATERIAL <br />A <br />U 5 ALUMINUM A U <br />6 CONCRETE <br />A <br />U 7 STEEL CLAD W/FRP <br />A U 8 100% METHANOL COMPATIBLE FRP <br />A <br />U 9 GALVANIZED STEEL AUo <br />95 UNKNOWN <br />A <br />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 QP S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br />VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br />1. ESTIMATED DATE LAST USED (MO/YR) <br />2. ESTIMATED QUANTITY OF <br />FACILITY ID # <br />0 o i e z, <br />3. WAS TANK FILLED WITH <br />�EN� TY ID # <br />E <br />u <br />T1 <br />SUBSTANCE REMAINING ININERT <br />GALLONS 1 <br />MATERIAL? <br />Y <br />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 />7 <br />LOCAL AGENCY USE ONLY <br />JURISDICTION # <br />AGENCY# <br />FACILITY ID # <br />0 o i e z, <br />TANK ID # <br />©o � <br />�EN� TY ID # <br />E <br />APPR D E <br />PHONE # WITH AREA CODE <br />PERMIT APPROVAL DATE <br />PERMITEXPIRATION DATE <br />PERMIT AMOUNT <br />SURCHARGE AMT. <br />FEE CODE RECEIPT # <br />BY: <br />FORM B (3-7-88) THIS FORM MUST BE ACCOMPAWWBY A FACILITY/SITE APPLICATION, FORM `A', UNLESMURRENT FORMA' HAS BEEN FILED <br />DATA PROCESSING COPY <br />;A <br />