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STATE OF CALIFORNIA WATER RESOURCES CONTRO' OARD <br /> FORM 'B': UNDERGROUND STORAGE TANK PRO XMAM ;�� <br /> TANK TANK PERMIT APPLICATION INFORMATION � <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. " z <br /> 10 <br /> MARK ONLY 1 NEW PERMIT F-] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLYC S K <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED of <br /> iv <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: _t(_/ FARM TANK-YES❑ NO ()'i <br /> u <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY IV <br /> A. OWNERS TANK IDP 'Z/ B. MANUFACTURED BY: CA) <br /> C 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. <br /> A. M 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL <br /> 3 CHEMICALPRODUCT �4 OIL E] 1 PRODUCT ❑4 GASAHOL 0 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS 80 EMPTY ❑95 UNKNOWNr�fr2WASTE 7 METHANOLOTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> C.A.S.R: <br /> yJ�I..C/ <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.K <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A. TYPE OF ❑ 1 OUBLEWALLED 3 SINGLE WALLED WITH EXTERIOR UNER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEBUIRON 2 STAINLESS STEEL F-1 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK 5 CONCRETE 6 POLYVINYLCHLORIDE F-� 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> 9 BRONZE 10 GALVANIZED STEEL 0 95 UNKNOWN 99 OTHER <br /> 1 RUBBER UNED ❑2 MMUNING ❑3 EPDXY LINING 4 PHENOUC LINING <br /> C. INTERIOR <br /> UNLINED UNKNOWN. <br /> LINING ❑ 5GLASS LINING <br /> , /_ <br /> [-] IS UNING MATERIAL COMPATIBLE WITH 900%MENIANOL? YES [:] NO OTHER (/ZM/ry <br /> D. CORROSION ❑ I POLYETHLENEWRAP ❑2 TAR OR ASPHALT3 1NYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION E]5 CATHODIC PROTECTION 91 NONE UNKNOWN El 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IFUNDE ROUND,BOTH IFAPPLICABLE <br /> A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A(Ufi GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B. CONSTRUCTION A 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 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUM A ,6 CONCRETE A U 7 STEELCLADW/FRP A U B 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL U-'^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 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS , <br /> P 5 6 PRECISION TESTIN 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.ESTIMAT DATELAST USED(MO/YR) 2. ESTIMTED QUANTITY OF 3.WA NK FILLED WITH <br /> SUB E REMAINING IN ATERIAL? YES NO <br /> GALLONS I <br /> THIS FORM HAS BEEN COMPLETED UNDER PENAL OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. i <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION <br /> RIm# AGENCY R FACILITY ID R TANK ID M <br /> Uo In <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROYJ:D BY NAME PHONE p WITH AREA CODE <br /> 2� 1411- 1 <br /> PERMIT NUMBER PERMITAPPRO LO PERMIT EXPIRATION DATE <br /> V11- /2 v/ <br /> CHECK* PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: <br /> _.� FORM B(6-29-55) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />