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STATE OF CALIFORN140 WATER RESOURCES CONTRO ..... <br /> STORAGE TANK PROGRAM ...RAM <br /> FORM B . UNDERGROUND - <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> O LETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> 10 <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM El 2 INTERIM PERMIT 4 AMENDED PERMIT E]6 TEMPORARY TANK CLOSURE 8 TANK REMOVED O <br /> � � �jL W � <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: ILRJr,M/Ilwl FARM TANK-YES E] NO W <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY % <br /> A. OWNERS TANK 10# B. MANUFACTURED BY: c" <br /> C.YEAR INSTALLED ( t` D. TANK CAPACITY IN GALLONS: 0o 1 <br /> 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. I+ <br /> A, '1MOTOR VEHICLE FUEL F-�2 PETROLEUM B. C. F-1 1 UNLEADED 2 LEADED Efr3 DIESEL 1 <br /> 3 CHEMICAL PRODUCT �4 OIL 1 PRODUCT E]4 GASAHOL 5 JET FUEL ION GAS <br /> 5 HAZARDOUS ED80 EMPTY [:] 95 UNKNOWN E]2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) i <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF 1 <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: AJ14 <br /> I11. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF 1 DOUBLE WALLED F-�3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED [:]4 SECONDARY CONTAINMENT 99 OTHER +1111 <br /> 1 STEEL/IRON ❑2 STAINLESS STEEL F�3 FIBERGLASS 0 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC { <br /> B.TANK <br /> MATERIAL 5 CONCRETE El6 POLYVINYLCHLORIDE 7 ALUMINUM lrJ 8 100%MEI <br /> 9 BRONZE El10 GALVANIZED STEEL 95 NKNOWN 99 OTHER II <br /> 1 RUBBER LINEDALKYD LINING PDXY LINING E]4 PHENOLIC LINING LJ <br /> C.INTERIOR i <br /> LINING ❑5 GLASS LINING j6UNLIN �95 UNKNOWN <br /> i <br /> E] IS LINING MATERIAL COMP9 IBLE ITH 10D%METHANOL" Ej'YES [:] NO D 99 OTHER I <br /> D. CORROSION ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC I+1 <br /> PROTECTION 5 CATHODIC PROTECTION E]91 NONE 1:1 95 UNKNOWN 99 OTHER <br /> I <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A.SYSTEM TYPEU 1 SUCTION A 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&f 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A 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 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER <br /> ,,-Ir 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 WELLP 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 P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1.ESTIMATED DATE LAST SED(MO/YR) 2. ESTIMA D QUANTITY OF 3.WAS TANK FILLED WITH <br /> S B E REMAINING IN GALLONS IN T ATERIAL? YES D NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENAL OF PERJURY,AND TO THE BEST OF MY KNO LEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY 2j <br /> ENUMBER <br /> RISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> CILITY IDN APPROVED BY N PHONES WITH AREA CODE <br /> PERMIT APP VAL TE P RMIT PIRA ON DATE <br /> IT AMOUNT . RCHAAGE AMf I FEE CODE R IPT N BY: <br /> i <br /> V <br /> FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A', mENT FORMA' HAS BEEN FILED <br /> VVV nATA oanrEsslNr,r_nOY C <br />