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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. <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION El 7 PERMANENTLY CLOSED A <br /> ONE ITEM ❑2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 6 TEMPORARY TANK CLOSURE <br /> 8 TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: es _FARM TANK-YES NO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 1-7 <br /> IC <br /> A, OWNERS TANK ID B. MANUFACTURED BY: <br /> G 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. CN <br /> A, f-1 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED E:] 2 LEADED E]3 DIESEL 00 <br /> 3 CHEMICAL PRODUCT O 4 OILO <br /> 1 PRODUCT �4 GASAHOL � 5 JET FUEL [:]6 AVIATION GAS <br /> 5 HAZARDOUS [::] SO EMPTY 0 95 UNKNOWN ❑ 2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM 0,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED 8 C.A.S.R C.A.S.IF <br /> KIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.a D <br /> A TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM ❑2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> I STEEL/IRON 2 STAINLESS STEEL 3FIBERGLSS 4STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.MANTERIAL 5CONCRETE 6 POLYVINYL CHLORIDE 7ALUMINUM B IDA METHANOL COMPATIBLE FRP <br /> 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> C. INTERIOR I RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> LINING ❑5 GLASS LINING E:l 6 UNLINED Fj 95 UNKNOWN <br /> ISUNING MATERIAL COMPATIBLE WITH 100%METHAXOP YES E] No 93 OTHER <br /> D.CORROSION ❑ I 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 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 I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) 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 1O0 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 I 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 S 6 PRECISION TESTING P 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 /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL' YE$ NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION M AGENCY M FACILITY ID M TANK IO# <br /> EU = = 3 41 ' <br /> CURRENT LOCAL AOENq FACILITY ID N APPROVED Y <br /> BY AE <br /> / W/ PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE -MIT EAPIRATI DATE <br /> CHECK Y PERMIT AMOUNT I SURCHARGE AMT. FEE CODE RECEIPT Y BY: <br /> FORM B(3-7.06) THIS FORM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> UAFA Yffot:t-:G.nn;; C,.TPY <br />