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STATE OF CALIFORNWATER RESOURCES CONTR BOARD <br /> FORM 'B': UNDERGROUND STORAGE TANK PROGRAM ' M1 <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 RENEWALPERMIT 5 CHANGE OF INFORMATION 7 PE ANENTLY CLOSED TA 10 <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE RrTANK REMOVED .NS g <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: S FARM TANK-YES El NO / <br /> N <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN SO SPECIFY N <br /> A <br /> A. OWNERS TANK ID <br /> 9 B. MANUFACTURED BY: <br /> C. YEAR INSTALLED k <br /> D. TANK CAPACITY IN GALLONS: zr4 00 <br /> 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. MOTOR VEHICLE FUEL 2 PETROLEUMB. C. o 1 UNLEADED LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT 4 OIL PRODUCT 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS 80 EMPTY 0 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 8 C.A.S.R C.A.S.8: <br /> Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C.8 D <br /> A TYPE OF ❑1119OLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM Lr SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> STEELIIRON 2STNNLESS STEEL ❑3FIBERGLASS 4STEEL CLAD W/RBERGLASS REINFORCED PLASTIC <br /> B.TANK 5 CONCRETE 6 POLYVINYLCHLORIDE F-]7 ALUMINUM 810AMETHANOLCOMPATIBLEFRP <br /> MATERIAL <br /> 9 BRONZE 10 GALVANIZED STEEL ❑95 UNKNOWN W OTHER <br /> C. INTERIOR ❑ I RUBBER UNED 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> LINING ❑5 GLASS LINING ❑6 UNLINED Z4511INKNOWN <br /> ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑NO 99 OTHER i <br /> D.CORROSION ❑ 1 POLYETHLENEWR4P 2 TAO OR ASPHALT 3VI WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION E]5 CATHODIC PROTECTION 91 NONE UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A 4.,k PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B. CONSTRUCTION A 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 /> AZY> STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C. MATERIAL A Ir 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD 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 t VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS <br /> P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 8 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? 0 YES E]NO <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 B SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY ID# TANK ID N <br /> = = lAcj I= 101010151 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED PY NAME PHONE N WITH AREA CODE <br /> aY � <br /> PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK N PEPMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: <br /> FORM 3(6-29-66) THIS FORM MUST BE ACCOMPANIEy.WA FACILRY/SITE APPLICATION, FORM 'A',UNLESS A M. FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />