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STATE OF CALIFORNIA WATER RESOURCES CONTROL B RD <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 RENEWALPERMIT 5 CHANGE OF INFORMATION W / PE MANENTLY CLOSED TANK 10 <br /> ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMITrr 6 TEMPORARY TANK CLOSURE ANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: 11136 C, � FARM TANK-YES <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I) <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: A <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: (� <br /> 11. TANK CnNTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. G 1 MOT OR VEHICLE FUEL 0 2 P OLEUM FE5j��IWASTE <br /> C. 1 UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT OIL 1 PRODUCT ❑4 GASAHOL 5 JET EL 6 AVIATION GAS <br /> 5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN D 7 METHANOL OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF O S <br /> HAZARDOUS SUBSTANCE STORED&C.Awa r D rS.# / C.A.S.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,6 D <br /> A. TYPE OF ❑ 1 DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER EEr95 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED 4 SECONDARYCONTAINMENT ❑99 OTHER <br /> 1 STEEUIRON 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK5 CONCRETE 6 POLYVINYLCHLORIDE 7 ALUMINUM 81 D0%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> ❑9 BRONZE 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER <br /> C. INTERIOR ❑ I RUBBERUNED 2 ALKYD LINING 3 EPDXY UNING ❑4 PH OLICUNING <br /> LINING ❑5 GLASS UNING 6 UNLINED UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER <br /> D. CORROSION ❑ 1 POLYETHLENE WRAP 2 TARORASPHALT3 VINY WRAP 4 FIBERGLASS REINFORCED PLAS IC <br /> PROTECTION [j 5 CATHODIC PROTECTION 91 NONE NKNOWN 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& 5 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 U 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 U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U S 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL Ae95 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 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION • 8 WELLS P B 4 ELECTRONIC MONITOR P 6 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURETESTING S 91 N P B 95 UNKNOWN P B 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 /> GALLONS <br /> SUBSTANCE REMAINING IN 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(POINTED B SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> 160hi= D <br /> c7uRRGENT C L AGENCY FACILITY ID# APPROVED By NAM ^ y PHONE#WITH AREA CODE <br /> it) F <br /> PERMIT NUMBER •ERMITAPPROVALDATE P MIT EXPIRATIONDADATE <br /> N <br /> CHECKPERMIT AMOUNTSURCHARGE AMT. FEE CODE RECEIPT BY: <br /> /yFORM B(6-29-BBL-THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br />