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S r <br /> STATE OF CALIFORNI <br /> f WATER RESOURCES CONTRIUMOARD <br /> .. <br /> FORM `B': UNDE GROUND STORAGE TANK PRRAM 'T <br /> 0 <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> 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 P ANENTLY CLOSED T <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: t5q�,,rFARM TANK-YES❑ NO N <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK ID# / B. MANUFACTURED BY: /i co <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL <br /> F-13 CHEMICAL PRODUCT I/4 OIL El P ODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS <br /> ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑%UNKNOWN 2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHIN FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCV STORED&C.A.S.# C.A.S.#: <br /> III. TANK CONSTRUCTI MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF ❑ 1 DOUBLE WALLE ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN <br /> SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER <br /> ❑ 1 STEEL/IRON \ENYL <br /> LESS STEEL F-1 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK ❑ 5 CONCRETE ICHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> ❑9 BRONZE ANIZED STEEL ❑95UNKNOWN ❑99 OTHER <br /> ❑ 1 RUBBER LINED ❑ 2 ALKYD L ING ❑3 EPDXY LINING ❑ 4 PHENOLIC LINING <br /> C.INTERIOR <br /> LINING ❑5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN <br /> ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL. ❑YES ❑ NO ❑99 OTHER <br /> D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT 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 DERGROUND,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 \OT <br /> YL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U LADW/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> k A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U <br /> I <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY, 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 ELEC ONIC 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 UNKN N 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? E]YES ❑ NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KN LEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DA <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> 3 II El I I Inlol 1 13>1 Enlolo -1111 <br /> CURRENn AG^ENCY FACILITY ID# APPROVERBY NAME PHONE#WITH AREA CODE <br /> V <br /> PERMIT NUMBER PERMIT APPROVAL D E PERMIT EXPIRATION DATE <br /> CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT <br /> FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIE BY A FACILITY/SITE APPLICATION, FORM.'A',UNLESS, RRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />