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STATE OFCALIFORNIft WATER RESOURCES CONTROSDARD b•';.�:;r,� <br /> FORM `B': UNDE GROUND STORAGE TANK PROCaRAM <br /> �.o <br /> TANKTANK PERMIT APPLICATION INFORMATION <br /> ,P <br /> 1LI PLETE A SEPARATE FORM WITH THE FOLLOWING NF R RN <br /> CO O I O MATION FOR EACH TANK. — <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION F-1 7 PERMANENTLY CLOSED TANK I <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED 61 / <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: 3�Z j 2jLV 7, Z C FARM TANK-YES❑ NO C3"I <br /> IV <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY N <br /> A. OWNERS TANK ID# 00 <br /> B. MANUFACTURED BY: <br /> C. YEAR INSTALLED �J D. TANK CAPACITY IN GALLONS: 1 Z <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. []3--1'MOTOR VEHICLE FUEL 2 PETROLEUM B. C. 1 UNLEADED 0 2 LEADED E313 DIESEL <br /> 3 CHEMICAL PRODUCT 4 OIL Erl PRODUCT ❑4 GASAHOL 5 JET FUEL E 6 AVIATION GAS <br /> 5 HAZARDOUS 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 <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE of ❑i DOUBLE WALLED F-1 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED 0 4 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEEL/IRON F-1 2 STAINLESS STEEL r-j 3 FIBERGLASS F-1 4 STEEL GLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK 5 CONCRETE6 POLYVINYLCHLORIDE F-17 ALUMINUM 0 8 100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> 9 BRONZE [::] 10 GALVANIZED STEEL [:]95 UNKNOWN Ej 99 OTHER <br /> C.INTERIOR 1 RUBBER LINED El 2 ALKYD LINING F-13 EPDXY UNING F-14 PHENOLIC LINING <br /> LINING ❑5 GLASS LINING F-1 6 UNLINED E]95 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES F] NO 99 OTHER <br /> D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TARORASPHALT F-�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 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 U 1 SINGLE WALLED A U 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 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 8 100%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 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 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) 2. ESTIMATED OUANTITY 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 /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> Io�rr( o <br /> CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE REC IPT# By: <br /> FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED B . ACILITY/SI1E APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />