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STATE OF CALIFORNI WATER RESOURCES CONTROARD <br />FORM `B': UND ROUND STORAGE TANK PROGRAM <br />TANK PERMIT APPLICATION INFORMATION <br />TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br />MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ®-5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK <br />ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED 1,.S--- <br />FACILITY/SITE NAME WHERE TANK IS INSTALLED: !Z �3 77-/ FARM TANK - YES ❑ NO <br />I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY <br />A. OWNERS TANK ID # B. MANUFACTURED BY: e XE -5 <br />C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: [Q <br />II. TANK CONTENTS IF (A.1). IS MARKED. COMPLETE ITEM C. IF (A.11. IS NOT MARKED. COMPLETE ITEM D- <br />A. I R 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM <br />B. <br />C. ❑ 1 UNLEADED � LEADED ❑ 3 DIESEL <br />❑ 3 CHEMICAL PRODUCT ❑ 4 OIL <br />�1 PRODUCT <br />❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS <br />❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN <br />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. # C.A.S. #: <br />xIIl- TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D <br />A. TYPE OF <br />❑ I DOUBLE WALLED <br />❑ 3 SINGLE WALLED WITH EXTERIOR LINER <br />❑ 95 UNKNOWN <br />SYSTEM <br />15? SINGLE WALLED <br />❑ 4 SECONDARY CONTAINMENT <br />❑ 99 OTHER <br />A <br />F-11 STEEL/IRON <br />❑ 2 STAINLESS STEEL <br />RT3 FIBERGLASS <br />F-14 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br />B. TANK <br />MATERIAL <br />❑ 5 CONCRETE <br />E]6 POLYVINYLCHLORIDE <br />❑ 7 ALUMINUM <br />❑ 8 100% METHANOL COMPATIBLE FRP <br />A <br />❑ 9 BRONZE <br />❑ 10 GALVANIZED STEEL <br />❑ 95 UNKNOWN <br />❑ 99 OTHER <br />U 5 ALUMINUM A U <br />F-]1 RUBBER LINED <br />[-]2 ALKYD LINING <br />F-13 EPDXY LINING <br />❑ 4 PHENOLIC LINING <br />C. INTERIOR <br />LINING <br />❑ 5 GLASS LINING <br />06 UNLINED <br />95 UNKNOWN <br />❑ 95 UNKNOWN <br />U 99 OTHER <br />❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? <br />❑ YES ❑ NO <br />❑ 99 OTHER <br />D. CORROSION <br />❑ 1 POLYETHLENE WRAP <br />❑ 2 TAR OR ASPHALT <br />❑ 3 VINYL WRAP <br />❑ 4 FIBERGLASS REINFORCED PLASTIC <br />PROTECTION <br />❑ 5 CATHODIC PROTECTION <br />So 91 NONE <br />❑ 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 />A <br />U 1 SUCTION A(g) <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 AeO <br />95 UNKNOWN A U 99 OTHER <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 A (D <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 />0:5, I P 6 PRECISION TESTINGS 7 PRESSURETEST NG RECONCILIATION F S 91NONE <br />WELLS P S 95ELECTRONIC UNKNOWN MONITOR P C �99GOTOHERD W�� M NITORIJdG V LL$ I, j <br />VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br />1. ESTIMATED DATE LAST USED (MO/YR) <br />2. ESTIMATED QUANTITY OF <br />3. WAS TANKF,ILLED WITH <br />FACILITY ID # / % <br />SUBSTANCE REMAINING IN <br />IN ERT MATERIAL? ❑ YES ❑ NO <br />GALLONS <br />PHONE # WITH AREA CODE <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />APPLICANTS NAME (PRINTED & SIGNATURE) DATE <br />LOCAL AGENCY USE ONLY <br />COUNTY # <br />JURISDICTION # <br />AGENCY # <br />FACILITY ID # / % <br />TANK ID # <br />[016EVI <br />CURRENT LOCAL AGENCY FACILITY ID # <br />APPROVED BY NAMES <br />;?- �Q b <br />PHONE # WITH AREA CODE <br />PERMIlIT NUMBER <br />PERMIT APPROVAL DATE <br />PERMIT RATI ATE <br />CHECK # <br />PERMIT AMOUNT <br />SURCHARGE AMT. <br />FEE CODE <br />RECEIPT # <br />F'Y- <br />FORM <br />B (3-7-88) THIS FORM MUST BE ACCOMPANIEdWA FACILITY/SITE APPLICATION, FORM `A', UNLESS A MRENT FORMA' HAS BEEN FILED <br />DATA PROCESSING COPY <br />