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STATE OF CALIFORNIA* WATER RESOURCES CONTROL ORD " <br /> FORM 'B': UNDERGROUND STORAGE TANK PROGRAM <br /> TANK PERMIT APPLICATION INFORMATION ', `P <br /> TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING NFORMATION FOR EACH TANK. z <br /> to <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 21�5'CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT (f ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: a ,J, / FARM TANK-YES Q NO ❑ CA) <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY CA) <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: wK <br /> C. YEAR INSTALLED L< 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 ❑ 4 OILF-11 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL [:] 6 AVIATION GAS <br /> ❑ 5 HAZARDOUS ❑ 80 EMPTY ,L-pj 9 /UNUNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.B.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF ❑ 1 00 LE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER3w;lUNKNOWN <br /> SYSTEM INGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER <br /> 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE 7 MINUM ❑ 8 108%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER <br /> ❑ 1 RUBBER LINED ❑ 2 A XYDLINING ❑ 3 EPDXY LINING 4 P NOCK LINING <br /> C. INTERIOR UNKNOWN <br /> LINING ❑ 5 GLASS LINING UNLINED <br /> ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? E]YES ❑ NO 99 OTHER 14 <br /> D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYLWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE �5 UNKNOWN ❑ 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE ASUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B. CONSTRUCTION AM 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 /> U 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 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL 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 3 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P DOSE WELLS P 3 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P 3 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NE 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? ❑YES E] NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION k AGENCY# a_ t TANK ID N <br /> mCURRENT LOCAL AGENCY FACILITY ID N M APPR VED BY NAPHONE N WITH AREA CODE <br /> PERMIT NUMBER ERMIT APPROVAL DA PERMIT EXPIRATION DATE <br /> CHECK k PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: <br /> FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />