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STATE OF CALIFORNIA* WATER RESOURCES CONTROVFARD <br /> FORM `B': UNDERGROUND STORAGE TANK PRO AM ; m' <br /> TANKTANK PERMIT APPLICATION INFORMATION <br /> NK. <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TAZ <br /> MARK ONLY ❑ 1 N ERMIT F-] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLO EDT <br /> ONE ITEM 2 INTERIM PERMIT F--j 4 AMENDED PERMIT E] 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO .I"' <br /> l � <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A <br /> A <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: <br /> GALLONS: <br /> C. YEAR INSTALLED U <br /> D. TANK CAPACITY IN G U U O <br /> II. TANK CcWTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL E] 2 PETROLEUM C. ❑ 1 UNLEADED 2 LEADED EL <br /> 0 3 CHEMICAL PRODUCT ❑ 4 OIL 8. 1 PRODUCT ❑ 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> ❑ 5 HAZARDOUS E] 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 A ` C.A.S.#: <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# '✓ /� <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,&D <br /> A TYPE OF ❑ I DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER NKNOWN <br /> SYSTEM ❑2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> ❑ 1 STEEUIRON F7 2 STAINLESS STEEL [:] 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK 5 CONCRETE F-�6 POLYVINYLCHLORIDE Q 7 AL M 8108%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> 9 BRONZE 10 GALVANIZED STEEL 5 UNKNOWN 59 OTHER <br /> I RUBBER UNED 2 ALKYD LINING 3 EPDXY LINING 4 PH IC LINING <br /> C. INTERIOR <br /> LINING ❑5 GLASS UNING 6 UNUNED 95 UNKNOWN <br /> ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? �YES D NO �990THER <br /> D.CORROSION ❑ I POLYETHLENE WRAP 2TAR OR ASPHALT 3VINY P 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION E]5 CATHODIC PROTECTION 91 NONE L±44UNKNOWN 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 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 UNED TRENCH A U 91 NONE U 5 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYLCHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUM AU CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A 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 1VISUALCHECK P 21 NVENTORYRECONCILIATION P S 3VADOSEWELLS P S 4ELECTRONIC MONITOR P S SG ROUND WATER MONITORING WELLS <br /> 11`71/CJI'/ <br /> FPS PRECISION TESTING P S 7 PRESBURE TEBTING 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 LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E]YES L] 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 A,SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# T�AGENCY# FACILITY ID# TANK ID# <br /> lo I 3 I�� t)I '�?- / <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE ERMIT EXPIRATION DATE <br /> CHECKN PERMIT AMOUNT SURCMARGE AMT. FEE CODE RECEIPT# BY: <br /> FORMB(5-29-88) THIS FORM MUST BEACCOMPANIE YAFACILITY/SITE APPLICATION, FORM `A',UNLESS A RENT FORMA' HASBEENFILED <br /> DATA PROCESSING COPY <br />