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77 <br /> STATE OF CAtIFORNI fa WATER RESOURCES CONTR ARD <br /> FORM `B': UNDE GROUND STORAGE TANK PRO AM ' <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY ❑1 NEW PERMIT F-1 3 RENEWAL PERMIT CHANGE OFINFORMATION 7 PERMANENTLY CLO4TANK <br /> ONE ITEM 2 INTERIM PERMIT �4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED FACILITY/SITE NAME WNERE TANK IS INSTALLED: <br /> .FARM TANK-YES❑ <br /> 10 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK ID# (Vk B. MANUFACTURED BY: Ut4k, <br /> C.YEAR INSTALLED U D. TANK CAPACITY IN GALLONS: w <br /> II. TANK TENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A 1),IS NOT MARKED,COMPLETE ITEM D. <br /> N <br /> A. 1 MOTOR VEHICLE FUEL 2 PETROLEUM B�e2 <br /> C. ❑ 1 UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT 4 OIL ODUCT ❑4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS 80 EMPTY 95 UNKNOWN STE7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF ` C.A.S.#: <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# �I <br /> All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A TYPE OF ❑ 1 DOUBLE WALLED F-]3 SINGLE WALLED WITH EXTERIOR UNER UNKNOWN <br /> SYSTEM F1 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT E]99 OTHER <br /> 1 SIEEUIRON 2 STAINLESSSTEEL 3 FIBERGLASS Ej 4 STEEL CLAD WIRBERGLASS REINFORCED PLASTIC <br /> B.TANK F-1 5 CONCRETE 6 POLYVINYLCHLORIDE ❑7>UMNUM 0 B 100%METHANOLOOMPATIBLEFRP <br /> MATERIAL ❑9 BRONZE F-1 10 GALVANIZED STEEL 95 UNKNOWN 0 99 OTHER <br /> 1 RUBBER UNED [:]2 ALKYD LINING 3 EPDXY LINING 0 4 OUC UNING <br /> C.INTERIOR 5 GLASS UNING F-16 UNUNED %UNKNOWN <br /> LINING <br /> IS UNING MATERIALCOMPATIBLE WffH 100%MEfHANOL? E]YES EI NO 0 99 OTHER <br /> D. CORROSION ❑ T POLYETHLENEWRAP F-1 2 TAR OR ASPHALT3 VI WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION F-]5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER <br /> IV. PIPING INFORMAT ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 5 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYLCHLORIDE(PVC) A U 4 FISERGLASSPIPE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A 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 S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P PRECISION TESTING P S 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 /> 1. ESTIMATED DATE LAST ED(MO YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? YES NO <br /> 14t THIS FORM HAS AFEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> Fc]) ZED] <br /> E <br /> APPROVEDB NAMEPHONE#WITH AREA CODE <br /> ENCY FACILITY IDM q PERM IT APPROVAL DATE PE MIT EKPIRATI DATE <br /> PERMITAMOUNT SURCHARGE AMT. FEE CODE RECEIPT BY: <br /> FORM B S-7-BB) THIS FORM MUST BE ACCOMPANILU BY A FACILITY/SSIA APPLICATION,PROCESSINGORMD 'A',UNLESS RRENT FORMA' HAS BEEN FILED <br />