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STATE OF CALIFORNIi WATER RESOURCES CONTROSOARD <br /> FORM `B': UNDE ROUND STORAGE TANK PRO AM <br /> TANKTANK PERMIT APPLICATION INFORMATION <br /> TANK. <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH :r <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT D 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM k 2 INTERIM PERMIT El 4 AMENDED PERMIT 0 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED 0 <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: 4All FARM TANK-YES❑ NO -� <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> CD <br /> A. OWNERS TANK ID# `T/ B. MANUFACTURED BI <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. [�1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT E] 4 OIL ©'1 PRODUCT 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> E] 5 HAZARDOUS F-] BO EMPTY ❑ 95 UNKNOWN 2 WASTE ❑ 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.N: <br /> HAZARDOUS SUBSTANCE STORED&, q <br /> III. TANK CONSTRUCTION MARK ONE ITEM O LY IN BOX A,B,C.&D <br /> A.TYPE OF ❑}DOUBLEWALLED F-] 3 SINGLE WALLED WITH EXTERIOR LINER � 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED F-�4 SECONDARY CONTAINMENT E] 99 OTHER <br /> 1 STEEL/IRON F-1 2 STAINLESS STEEL F-�3 FIBERGLASS E]4 STEEL CUD WI FIBERGLASS REINFORCED PLASTIC <br /> B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE F--] 7 ALUMINUM 8100%METHANOL COMPATIBLE FRP <br /> MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL F] 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED ❑2 ALKYD LINING F-1 3 EPDXY LINING E]4 PHENOLIC LINING <br /> C. INTERIOR F-1 5 GLASS LINING ❑- 6 UNLINED ❑ 95 UNKNOWN <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? VES [:] NO 99 OTHER <br /> D. CORROSION ❑ 1 POLYEFHLENEWRAP ❑ 2 TARORASPHALT 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 0 91 NONE 095 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 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 1 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 �CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A 5 UNKNOWN A U 99 OTHER <br /> EAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P 1VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> `J 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE IT USED(MO/YR) 2. ESTIMATED O ANTITY OF 3. WAS TA K FILLED WITH <br /> SUBSTA C INING IN GALLONS IN T ERIAL? YES D NO <br /> THIS FORM HA BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWL DGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> [-C)16 / 1 O= <br /> CURRENN�T LL•OCAL AGENCY FACILITY ID N APPROVED BY NAME 2 PHONE N WITH AREA CODE <br /> PERMIT NUMBER �/ P IT A/PPR VAL DA PE MIT E%PI A I N DATE <br /> bW- <br /> CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: <br /> FORM B(6-29-88) THIS FORM MUST BE ACCOMPAIIY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS JRRENT FORMA' HAS BEEN FILED S <br /> DATA PROCESSING COPY <br />