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STATE OF CALIFORNIO WATER RESOURCES CONTROOOARD ' <br /> FORM 'B': UNDERGROUND STORAGE TANK PROGRAM m= <br /> TANKTANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> 10 <br /> MARK ONLY ❑ 1 NEW PERMIT Ej 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLYCLOS <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED(t <br /> CA) <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: W p FARM TANK-YES❑ NO w <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> ! CA) <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS. Zj� /%/ u7ro <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. OTOR VEHICLE FUEL 2 TROLEUM B. C. 1 UNLEADED 2 LEADED 3 DIESEL <br /> EV3HEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑ 4 GASAHOL n 5�ZF FUEL 6 AVIATION GAS <br /> ❑ 5 HAZARDOUS Ej BO EMPTY ❑95 UNKNOWN 2 WASTE 7 METHANOL Lin 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D HAZAARDOUSSUBSTANCE STORED&C.A.S.#CLE FUEL,ENTER NAME OF Cleo rre flew 1v 7,,�4g4, <br /> VK:/ C�� C.A.S #: <br /> 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXA,B,C,BD <br /> A.TYPE OF ❑ 1 UBLE WALLED ❑3 SINGLE WALLED WITH BGERIOR UNER 95 UNKNOWN <br /> SYSTEM 2 SI LE WALLED4 SECONDARY CONTAINMENT 99 OTHER <br /> STEEUIRON 2 STAINLESS STEEL 3FIBERGLASS 4STEEL CLADWIFIBERGNSS REINFORCED PLASTIC <br /> B.TANK 5 CONCRETE 6 POLYVINYLCHLORIDE 7 ALUMINUM 8100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> 1 RUBBERLINED ❑2 ALKYD LINING 3 EPDXYLINING n yrHENOLIC LINING <br /> C. LINING <br /> N NRGGR F-15 GLASS LINING F-16 UNLINED �u.�(95 UNKNOWN' <br /> 0 IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? 0 YES <br /> ��� ❑ NO 599 OTHER <br /> D. CORROSION F-] 1 POLYETHLENEWRAP 2 TAR OR ASPHALT NYLWRAP [:]4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑5 CATHODIC PROTECTION 91 NONE Ly 995 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 2 PRESSURE A U 3 GRAVITYA U 91 NONE A 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 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUM A M-%6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A UU95 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 /> .1 S 1VISUAL CHECK P S 21NVENTORY RECONCILIATION B 3VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS <br /> N P S 6 PRECISION TESTING P S 7 PRESSURE TES ING P 8 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 FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS I <br /> INERT MATERIAL? E]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 A SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> () I ol t I 2TMIc� ul o 131 <br /> CURRENT LOCAL AGENCY FACILITY ID 9L) APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE C <br /> CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE ECEIPT# <br /> FORM B(6-2988) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />