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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'B': UNDERGROUND STORAGE TANK PROGRAM <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - z <br /> 0 10 <br /> MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PEAMANENTLYC^SEDTANK <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDEOPERMIT ❑fi TEMPORARY TANK CLOSURE 8 TANK REMOVE // <br /> �^ �j F+ W <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: CMl o l4V FARM TANK-YES❑ NO N <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY N <br /> A. OWNERS TANK IDR B. MANUFACTURED BY: G(ivl N <br /> C. YEAR INSTALLEDZj�zD. TANK CAPACITY IN GALLONS: 3 <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE IT <br /> D. <br /> A. Ffj�l MOTOR VEHICLE FUEL ❑ 2 PETROLEUM Fr7STE <br /> . ❑ 1 UNLEADED ❑ 2 LEADED DIESEL <br /> ❑3 CHEMICAL PRODUCT ❑ 4 OIL ❑4 GABAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS <br /> ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑7 METHANOL ❑1)9 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.R /V C.A.S.R: <br /> Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D <br /> A. TYPE OF DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER <br /> 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. MATERIAL TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP <br /> ❑ 9 BRONZE ❑ 18 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER <br /> C. INTERIOR ❑ I RUBBER LINED ❑p2UKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC UNING <br /> LINING ❑5 GLASS LINING 6 UNLINED ❑95 OKNOWN <br /> ❑ IS LINING MATERIAL COMPATIBLE WRH 10(Wo METHANOL? ❑YES ❑NO 99 OTHER <br /> D. CORROSION ❑ 1 POLYETHLENEWMP 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 IFA BOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> S.CONSTRUCTION A Wl 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 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE <br /> C. MATERIAL A /U1T' 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP <br /> A(l 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. 11 <br /> P 8 1VISUAL CHECK P S 2 INVENTORY RECONCILIATION P E 3VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P 8 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 /> L ESTIMA ED DATE LAST USED(MO/YR) 2. ESTIMATED DLA TITY OF 3. WAST NK FILLED WITH - <br /> / SUBSTANCE Fid !y 1NG IN 10/9 <br /> �jE{T� ERIAL? ❑YES ❑ NO <br /> �l/ JV GALLONS N <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. I <br /> APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION! AGENCY! FACILITY IDR TANKID# <br /> 3 ` = = 1 6 10 1 / = 1 DU 162 17 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE M WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATON DATE <br /> CHECK! PERMIT AMOUNT SURCHARGE AMT. FEECODE RECEIPT! BY: <br /> C' FORM B(6 29 9e) THIS FORM MUST BE ACCOMPANIEIY .A FAbCITY/SITE APPLICATION, FORM `A',UNLESS A LZ4RENf-f'0RMS BEEN FILED <br />