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STATE OF CALIFORNI 0 WATER RESOURCES CONTR( BOARD <br /> FORM 'B': UNDIMGROUND STORAGE TANK PROMIIRAM `� <br /> �� <br /> �j TANK PERMIT APPLICATION INFORMATION '�z° <br /> TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWIN NFORMATION FOR EACH TANK. Z <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL K <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE <br /> 1 8 TANK REMOVED 0 <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: �/ l/Q i4 eAL FARM TANK-YES NO ❑ IV <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECT <br /> 9s'3o Xcoo <br /> A. OWNERS TANK ID N B. MANUFACTURED BY: <br /> C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: <br /> II. TANK CONTENTS IF(A/),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. Ell UNLEADED 2 LEADED 3 DIESEL <br /> ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑ 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> ❑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.R C.A.S.%: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C.&D <br /> A TYPE OF ❑ 1 DOU&E WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER <br /> ❑ I STEELARON ❑2 STAINLESS STEEL F-13 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK <br /> MATERIAL ❑5 CONCRETE 6 POLYVINYLCHLORIDE F-17 ALUMINUM 8100%METHANOL COMPATIBLE FRP <br /> ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER <br /> C. INTERIOR F-] I RUBBER LINED E]2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOUC LINING <br /> LINING ❑ 5 GLASS UNING ❑6 UNLINED ❑95 UNKNOWN <br /> ❑ IS LINING MATERIAL COMPATIBLE WITH 1011%METHANOL' ❑YES ❑NO ❑ 99 OTHER <br /> D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ S 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 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B. CONSTRUCTION A U 1 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 I 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 U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U 6 100%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 8 1VISUAL CHECK P B 2 INVENTORY RECONCILIATION P 8 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 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 OUANTITY OF 3, WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? YES ❑ 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 /> COUNTY R JURISDICTION B AGENCY N FACILITY ID S TANK ID K <br /> CURRENT LOCAL AGENCY FACILITY ID S APPROVED BY NAME PHONE P WITH AREA CODE <br /> '0 5 <br /> PERMIT NUMBER [PERMIT DATE PERMIT EXPIRATION DATE <br /> CHECKS PERMIT AMOUNT SURCHARGE AIT. FEE CODE RECEIPT F By; <br /> � FORMS(6-29-68) THIS FORM MUST BE ACCOMPANIED BY A FACILFFY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />