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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'B': UNDERGROUND STORAGE TANK PROGRAM <br /> TANK PERMIT APPLICATION INFORMATION <br /> TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY F-11 NEW PERMIT 3 RENEWALPERMIT Di'S CHANGE OF INFORMATION 7 PERMANENTLY CLOSED T� <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOV Z �' <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED ' FARM TANK-YES NO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY IO) <br /> A. OWNERS TANK ID �T B. MANUFACTURED BI Y V4t <br /> C.YEAR INSTALLED 4 D. TANK CAPACITY IN GALLON . <br /> II. SANK C NTENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,C PLETE ITEM D. W <br /> A. Eff'l MOTOR VEHICLE FUEL 2 PETROLEUM B. C. 1 UNLEADED o 2 LEADED ❑ 3 DIESEL <br /> 3 CHEMICAL PRODUCT 4 OIL PRODUCT ❑ 4 GASAHOL Ej 5 JET FUEL ❑6 AVIATION GAS <br /> 5 HAZARDOUS ❑ 80 EMPTY Ej 95 UNKNOWN 2 WASjE 7 METHANOL D 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAMEOF 1 <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# !2 C.A.S.#: (.//��� /✓ <br /> XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,i D <br /> A TYPE OF 1 DOUBLE WAUH 3 SINGLE WALLED WITH EXTERIOR UNER 95 UNKNOWN <br /> SYSTE 12 SINGLE WALLED 4 SECONDARYOONTAINMENT 99 OTHER <br /> A❑I MRIIRON 2 STAINLESS STEEL F-1 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK klS <br /> MATER F-15 CONCRETE 6 POLYVINYLCHLORIDE 0 7 A INUM Ej 8100%METHANOL OOMPATIBLEFRP <br /> ❑9 BRONZE 10 GALVANIZED STEEL UNKNOWN 99 OTHER <br /> C. INTERIOR <br /> 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING 4 PH IC LINING <br /> " <br /> LINING ❑ 5 GLASS UNING 6 UNUNED UNKNOWN <br /> IS LINING MATERIALCDMPATIBLEWDH 10016METHWI-Vt YES L�. Il0 o99 OTHER �•/ <br /> D.CORROSIO 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT 3"RAP 4 FIBERGLASS REINFORCED PLASTIC 1 <br /> PROTECTION 5 CATHODIC PROTECTION ❑91 NONE EKUNKNOWN Ej 99 OTHER <br /> IV. PIPING INFO ATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER U ti <br /> B.CONSTRUCTIOW A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A UNKNOWN A U 99 OTHER <br /> )� A U 1 STEEL/IRON 'A U 2 STAINLESSSTEEL 'A U 3 POLYVINYLCHLORIDE(PVC) A U 4 FIBERGLASSPIPE <br /> C. MATERIAL /q AU 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U B 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A S UNKNOWN A U 99 OTHER <br /> V. LE ETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> 2Z <br /> P VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P 8 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 91 NONE P S 95 UNKNOWN P i 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> TIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> . / SUBSTANCE REMAINING IN INERT MATERIAL? YES <br /> GALLONS 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> ZyCOUNTY# JURISDICTION# AGENCY# FACILITY ID# 1 TANK ID# <br /> 101 O .119 13 rololol / <br /> CUR LOCAL AGENCY FACILITY ID,11 AP ED BY NAME P NE#WITH AREA CODE <br /> IS Iq <br /> NUMBER P IT APPROVAL bXfE PERMIT PIAATION ATE <br /> v <br /> CHECK# I <br /> SURCHARGEAMT. f FEE CODE _MCEIPT* BY: <br /> FORMS(3-7-93) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A ENT FORMA' HASBEEN FILED S <br /> DATA PROCESSING COPY <br />