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STATE OF CALIFORNO WATER RESOURCES CONTI+BOARD <br /> FORM 'B': UNDERGROUND STORAGE TANK PROGRAM <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. o <br /> G <br /> MARK ONLY F-1I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK I C <br /> ONE ITEM 2 INTERIM PERMIT q AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED o0 <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: j4�� � FARM TANK-YES NO/ N <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A <br /> A. OWNERS TANK IDN B. MANUFACTURED BY: <br /> C. YEAR INSTALLED N� D. TANK CAPACITY IN GALLONS: <br /> i a) o c? !_ <br /> II. TANK C TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL F--] 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED 3 DIESEL <br /> ❑ 3 CHEMICAL PRODUCT ❑ 4 OILODUCT 4 GASAHOL 5 JET FUEL ❑ 6 AVIATION GAS <br /> 5 HAZARDOUS ❑80 EMPTY 0 95 UNKNOWN 2 WASTE 7 METHANOL Ej 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.R C.A.S.R: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,AD <br /> A TYPE OF E] I,0OUBUE WALLED F-1 3 SINGLE WALLED WITH EXTERIOR UNER 95 UNKNOWN <br /> SYSTEM Y2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> El'i STEEUIRON 2 STAINLESS STEEL 0 FIBERGLASS 4STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK ❑5 CONCRETE 6 POLYVINYLCHLORIDE F-17 ALUMINUM 8 100%METHANOLCOMPATIBLEFRP <br /> MATERIAL <br /> 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER <br /> C. INTERIOR 1 RUBBER LINED 2 LINING F-13 EPDXY LINING 4 PHENOLIC LINING <br /> LINING ❑5 GLASS LINING 6 UNUNED 95 UNKNOWN <br /> ISUNING MATERIAL COMPATIBLE WITH IW%METHANOL? YES [-] NO 99 OTHER <br /> D.CORROSION ❑ I POLYETHLENE WRAP2 T RASPRALT 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 0 5 CATHODIC PROTECTION I NONE 95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A(9pI SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 5 UNKNOWN A U 99 OTHER <br /> A U I STEELPRON 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 U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B IBB%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZEDSTEEL A 1 j 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 /> tPP S I VISUAL CHECK {P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS <br /> 8 6 PRECISION TESTING S 7 PRESSURETESTING P S 91 NONE P B 95 UNKNOWN P 8 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MO7YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION X AGENCY M FACILITY ID M TANK ID M <br /> G^ o I i I d I�- ol © 1 v / <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BYNAME PHONE N WITH AREA CODE <br /> Pfd<<F.3i <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> \ CHECKS PERMIT AMOUNT RCHARGE AMT. FEE CODE "^EIPT N By; <br /> Cx� 6ig�, <br /> FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> DATA PR ..CSI O Y <br />