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STATE OF CALIFORM& WATER RESOURCES CON OARD <br /> 'S <br /> FORM `B': UND ROUND STORAGE TANK PR AMo <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING,1 FORMATION FOR EACH TANK. <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT XeWANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ANK REMOVED I <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: o��'.� N . T rrtCT 4 I (rtFARM TANK-YES❑ NO <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 00 <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: I�N <br /> C. YEAR INSTALLED uk4 D. TANK CAPACITY IN GALLONS: to v Q <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A [LI4'MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. LEADED ❑ 2 LEADED ❑ 3 DIESEL <br /> ❑ 3 CHEMICAL PRODUCT ❑ 4 OILE�J�P`RODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 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 y_A_ <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: <br /> x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER NKNOWN <br /> SYSTEM ❑ 2 SINGLE WALLED 4 SECONDARY CONTAINMENT E]99 OTHER <br /> ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 AL M ❑8 100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> ❑9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER <br /> C. INTERIOR <br /> F-11 RUBBER LINED El2 ALKYD LINING ❑ 3 EPDXY LINING E] 4 PHENO LINING <br /> LINING F-15 GLASS LINING F-16 UNLINED NKNOWN <br /> ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ®NO ❑ 99 OTHER <br /> D.CORROSION ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT ❑ 3 VINYL W P 714 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE NKNOWN ❑ 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 99 OTHER �f CJti <br /> B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 05 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 <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 d-1 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 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> PI�1Y� 6 PRECISION TESTING P S 7 PRESSURE TESTING P 1 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USVD(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES [:] NO <br /> THIS FORM HAS B EN 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 /> 7-ol F19 1 :71 VD <br /> CURRENT L AGENCY FACILITY ID# APPROVED BY PHONE#WITH AREA CODE <br /> yk� <br /> PERMIT NUMBER PERMIT APPROV 7LATE PE IT EXPIRATIO ATE <br /> CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: <br /> FORM B(3-7-88) THIS FORM MUST BE ACCOMPAN&A FACILITY/SITE APPLICATION, FORM'A',UNLESSIqWWRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />