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STATE OF CALIFORNIA* WATER RESOURCES CONTROL RD <br /> FORM `B': UNDERGROUND STORAGE TANK PROGM <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. P <br /> MARK ONLY 1 NEW PERMIT F-] 3 RENEWAL PERMIT AGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK <br /> ONE ITEMTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: fil FARM TANK-YES❑ NO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY C► <br /> A. OWNERS TANK ID# t B. MANUFACTURED BY: <br /> [ 90-3 <br /> SDAbovu <br /> C. YEAR INSTALLED I -1 D. TANK CAPACITY IN GALLONS: 3 OQ <br /> ll. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. i <br /> A. MOTOR VEHICLE FUEL F-1 2 PETROLEUM B. C. 1 UNLEADED 2 LEADED DIESEL <br /> 3 CHEMICAL PRODUCT 4 OIL PRODUCT ❑4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 0 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.# A C.A.S.#: /l/ <br /> All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF ❑ 1 DOUBLE WALLED F-1 3 SINGLE WALLED WITH EXTERIOR LINER EKUNKNOWN <br /> SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT [::]99 OTHER <br /> 1 STEEL/IRON F-12 STAINLESS STEEL FIBERGLASS F-] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK ❑ 5 CONCRETE E:]6 POLYVINYLCHLORIDE ❑7 ALUMINUM a 8 100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> 9 BRONZE 0 10 GALVANIZED STEEL [-]95 UNKNOWN 99 OTHER <br /> C.INTERIOR <br /> 1 RUBBER LINED E]2 ALKYD LINING El 3 EPDXY LINING 4 PHENO LINING <br /> LINING ❑ 5 GLASS LINING [:]6 UNLINED NKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES [::] NO E] 99 OTHER <br /> D.CORROSION ❑1 POLYETHLENE WRAP 2 TAR OR ASPHALT U3 VINYL AP 0 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION [:]5 CATHODIC PROTECTION 91 NONE 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 99 OTHER <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 5 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PY) 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 05 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 /> oP 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 PRECISION TESTING 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 /> I/��/® SUBSTANCE REMAINING IN GALLONS I <br /> INERT MATERIAL? YES ❑ NO <br /> THIS FORM HAS BEE 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# TTA�NK ID# r <br /> 4 U / �- V 1 O 1 <br /> CURRENT LOCAL AGENCY FA ILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT ERPERMIT APPROVAL DATFj PERMIT EXPIRATION ATE <br /> 11 <br /> -7 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: <br /> 4 <br /> FORM B(3-7-88) THIS FORM MUST BE ACCOMPA BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS RRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />