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1 m I r- yr L;ALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'B': UNDERGROUND STORAGE TANK PROGRAM <br /> TANK ' <br /> TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT CHANGE OFINFORMATION <br /> ONE ITEM O 7 PERMANENTLY CLOSED TANK <br /> ID 2 INTERIM PERMIT / AMENDED PERMIT 0 6 TEMPORARY TANK CLOSURE B TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED, I I1� <br /> FARM TANK-YESE1 NO <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS.IF UNKNOWN-SO SPECIFY IQ <br /> A. OWNERS TANK ID X Op I B. MANUFACTURED BY: K <br /> C. YEAR INSTALLEDW <br /> D. TANK CAPACITY IN GALLONS 1400 > <br /> H. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED, OMPLETE ITEM D. <br /> A I MOTOR VEHICLE FUEL 0 2 PETROLEUM B. C. <br /> LrjI UNLEADED 0 2 LEADED 3 DIESEL <br /> ❑3 CHEMICAL PRODUCT OIL �1 PRODUCT ❑4 GASAHOL 5 JET FUEL 0 6 AVIATION GAS <br /> ❑ 5 HAZARDOUS BD EMPTY 0 95 UNKNOWN 2 WASTE ❑7 METHANOL 99 OTHER(DESCRIBE IN REM D.BELOM <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED 6 C.A.S.X <br /> CAS.p: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,A D <br /> A TYPE OF 0 DOUIUWALLED E]3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM la�iSINGUWALLED O/SECONDARYCONTANMENT 99 OTHER <br /> B.TANK <br /> STEBJROR ❑2 STAINLESS STEEL 0 3 FIBERGLASS /STEEL CUD WIFIBERGLASS REINFORCED PLASTIC <br /> 0 5 CONCRETE <br /> MATERIAL ❑6 POIYWNYLf70.0RDE 0 7 ALUMINUM 6160%METHANOL COMPATIBLE RTP <br /> 09 BRONZE 0 10 GALVANIZED STEEL E]95 UNKNOWN 0 99 OTHER <br /> C. INTERIOR ❑ I RUBBER LIKED 2 ALM UMNG El 3 EPDXYUNNG 1 PHENOUCUMNG <br /> LINING ❑5 GLASS LINING 6 UHUNEO 95 UNKNOWN <br /> IS UMNG MATERIAL COMPATIBLE WITH 1W%MED W10L7 0 YES D NO 99 OTHER <br /> D.CORROSION ❑ 1 POLYER6ENEWRAP 2 TAR ORAS%1ALT 3 VINYL WRAP ❑1 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 0 5 CATHODICPR 0TECRON E]91 NONE 95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND.BOTH IF APPLICABLE <br /> AL.ESYSTnEM TYPE A 1 SUCTION A U 2 PRESSURE A U ]GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> RUCTION 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 MOTHER <br /> A LA I STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U K FIBERGLASS PIPEA U BI NONE <br /> AL A V S ALUMINVM A V 6 CONCRETE A� U 7 STEEL CLAD W/FRP A U B IBO%METMANOL COMPATIBLE FRP <br /> A U 9 GALVANIZEDSTEEL 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 E 1 VISUAL CHECK ► 2 INVENTORY RECONCILIATION P 6 3 VADOSE WELLS P D A ELECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELLS <br /> P 8 6 PRECISION TESTING P B 7 PRESSURE TESTING P D 91 NONE P • 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> F--FES-TIIIATED DATE LAST USED(MO/YR) 2 ESTIMATED QUANTITY OF <br /> 3. WAS TANKFILLE)WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL7 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 8 SIGNATURE) DATE <br /> 1 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY• JURISDICTION• AGENCY F FACILITY ID R TANK ID S <br /> o 0 0 <br /> CURRENTLOCAL AGENCY FACILITY IO F APPROVED SY NAME <br /> 0 PHONE 1 WITH ANEA CODE <br /> PERMIT NUMBER o PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK I PERMIT AMOUNT SURCHARGE AMT. FEE CODE <br /> RECEIPT I BY: �. <br /> FORM B(6-29.66) THIS FORM MUST BE ACCOYPANIE A FACILITY/SITE APPLICATION, FORM LA',UNLESS A,RENT FORMA' HAS BEEN FILED <br /> '"� DATA PROCESRIMI gnoV <br />