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STATE OF CALIFORN11b WATER RESOURCES CONTR10ARDFORM `B': UNDE GROUND STORAGE TANK PROAM <br /> TANK TANK PERMIT APPLICATION INFORMATION " <br /> JS <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK.(S <br /> MARK ONLY 1 NEW PERMIT �3 RENEWAL PERMIT 5 CHANGE OF INFORMATION El 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM 2 INTERIM PERMIT F-1 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: I TI�. L FARM TANK-YES E] NOgl <br /> Q <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY • <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: OA/0/ � <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: ZQ <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. r--j 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C Ej 1 UNLEADED D 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT ®4 OIL ® 1 PRODUCT ❑4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS 80 EMPTY 0 95 UNKNOWN Ej 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 ®1 DOUBLE WALLED F-�3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM ❑2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEEL/IRON 2 STAINLESS STEEL X3 FIBERGLASS F�4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK IF--'5 CONCRETE F-]6 POLYVINYLCHLORIDE 7 7 ALUMINUM E]8100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> 9 BRONZE El 10 GALVANIZED STEEL [:] 95 UNKNOWN 99 OTHER <br /> C. INTERIOR 1 RUBBER LINED E]2 ALKYD LINING F-]3 EPDXY LINING 4 PHENOLIC LINING <br /> LINING ❑5 GLASS LINING F-1 6 UNLINED 95 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES [:] NO 99 OTHER <br /> D.CORROSION ❑ 1 POLYETHLENE WRAP F�2 TAR OR ASPHALT F-]3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 0 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 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 O4 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©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 QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? 1:1YES F NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PqqyRY,,ANq 7�9 THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> Ilomm - s�r"i L Co t, ► ! !!o <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> [M I I I I E[ ol o1,3-L <br /> -F3-1 <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> / _Z7-� <br /> CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE fECEIPT# BY: �./ <br /> W <br /> FORM B(6-29-88) THIS FORM MUST BE ACCOMI Y A LITY/SITE APPLICATION, FORM `A',UNLESS A RRE FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />