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STATE OF CALIFOR WATER RESOURCES CONTROBOARD QO <br /> FORM 'B : LEND GROUND STORAGE TANK PR GRAMTANK TANK PERMIT APPLICATION INFORMATIONCOMPLETE A SEPARATE FORM WITH THE FOLLOWIN INFORMATION FOR EACH TANK.MARK ONLY ❑ I NEW PERMIT 3 RENEWALPERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLO NK <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: ,j Iva - S FARM TANK-YES NO <br /> L <br /> I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK ID N B. MANUFACTURED BY: , <br /> C. YEAR INSTALLED I / v 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 M 2 P LEUM B. C. 1 UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT OIL El 1 ODUCT 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS 80 EMPTY 95 UNKNOWN 2 WASTE El 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D.BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF Z ,/ <br /> HAZARDOUS SUBSTANCE STORED 8 CA.S.B C.A.S.#: <br /> 111. TANK CONSTRUCT ON MARK ONE ITEM ONLY IN BOXA,8,C,8 D <br /> A.TYPE OF ❑ 1 WALLED -]3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEEL/IRON 2STAINLESS STEEL 3FIBERGLASS 4STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> BTANK MATERIAL 5CONCREfE E]6 POLYVINYL CHLORIDE Q1 INUM 8100%METHANOL COMPATIBLE FRP <br /> 9 BRONZE E] 10 GALVANIZED STEEL UNKNOWN 99 OTHER <br /> C.INTERIOR 1 RUBBER LINED E]2 ALKYD LINING 3 EPDXY UNING E] 4 PHENOLIC LINING <br /> LINING ❑ 5 GLASS LINING El 6 UNLINED 95 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES 0 NO 99 OTHER <br /> D. CORROSION ❑ 1 POLYETHLEME WRAP 2 TARORASPHALT 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IFAPPLICABLE <br /> A SYSTEM TYPE A U 1 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 95 UNKNOWN A U 99 OTHER �i <br /> A U I STEEL/IRON A U 2 STAINLESSSTEEL A U 3 PO L VINYL 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 8 100%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 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> I. ESTIMATED DATE UST 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 /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY B JURISDICTION <br /> # nnAGENCY 8 FACILITY ID P TANK ID R <br /> d 0 Z '? <br /> CURRENT LOCAL AGENCY EACILITY <br /> -ID t Y APPROVED BY NAME PHONE t WITH AREA CODE, <br /> PERMIT NUYBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECKt PERMIT AMOUNT SURCHARGE AMT. FEE CODE RE Tt <br /> BY:� <br /> FORM B(6-29-68) THIS FORM MUST BE ACCOMPANIED FICILITY/SIRE APPLICATION, FORM 'A',UNLESS A CURRENT FORM'A' NAS BEEN FILED <br /> DATA PROCESSING COPY <br />