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STATE OF CALIFORN' "i WATER RESOURCES CONTRr ' 30ARD <br /> FORM 'B': UNITEMf;GROUND STORAGE TANK PRCMRAM <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING FORMATION FOR EACH TANK. <br /> iC <br /> MARK ONLY ❑ 1 NEW PERMIT F-1 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM 7 2 INTERIM PERMIT 0 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> W <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: 707 E. em M FARM TANK-YES❑ NO (,V <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A <br /> CID <br /> A. OWNERS T INK ID a B. MANUFACTURED BY: <br /> C. YEAR INSTALLED (o L4. D. TANK CAPACITY IN GALLONS. <br /> 11. TANK CONTENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(A7),IS NOT MARKED,COMPLETE ITEM D <br /> A. MOTOR VEHICLE FUEL 7 2 PETROLEUM 8. C. 1 UNLEADED 2 LEAOED 3 DIESEL <br /> 3 CHEMICAL PRODUCT F7 4 OIL PRODUCT ❑ 4 GASAHOL E] 5 JET FUEL E] 6 AVIATION GAS <br /> EMPTY HAZARDOUS BO EMP95 UNKNOWN 112 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.a A4/A- C.A.S.a: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,c,a D <br /> A.TYPE OF ❑ 1 DOUBLE Wl F-� 3 SINGLE WALLED WITH EXTERIOR UNER 95 UNKNOWN / <br /> SYSTEM [;J-Y'4RCiLE WALL® 0 4 SECONDARY CONTAINMENT El 99 OTHER � B <br /> STEEUIRON F1 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC 1 <br /> B.TANK 5 CONCRETE F1 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM 8100%METHANOL COMPATIBLEFRP <br /> MATERIAL <br /> 9 BRONZE E] 70 GALVANIZED STAR 0 95 UNKNOWN Ej 99 OTHER <br /> 1 RIMBRUNED 2AU%D UNING 3EPDXY UNING 4PHENOUC UNING <br /> LINING <br /> C. INTERIOR 5 G *1ENG 6 UNJNED 95 UNKNOWN <br /> 0 IS UNING MATEPoAL OOMPATIBLE MTH 10096 METHANOL? YES 99 OTHER <br /> D.CORROSION ❑ 1 POLYETHLENEWHAP TAR OR ASPHALT F-1 3VINYL 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 IF APPLICABLE <br /> A SYSTEM TYPE A U 1 SUCTION A(g 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 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 7U -95 UNKNOWN A U 99 OTHER <br /> A U I 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 U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL AOU 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 GROUNDWATER MONITORING WELLS <br /> Iy J P PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> V I. 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 /> N I SUBSTANCE REMAINING IN . GALLONs INERT MATERIAL? F]YES Ej 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 a JURISDICTION M AGENCY a 'j FACILITY IDM 4/;3 TANK 10 B 'y' <br /> l <br /> 3 � I 1 <br /> I <br /> CURRENT LOCAL AGENCY FACILITY ID• APPROVED"�BY NAME ^� PHONE a WITH AREA CODE <br /> tj <br /> -R5 70 —y„ r G y <br /> PERMIT NUMBER <br /> PERMIT APPROVAL DATE <br /> PERMITUPN DATE <br /> CHECK PERMIT AMOUNT SURCl/MGE ANY. FEE CODE RE':EIPTF BY: <br /> FORM B(6-29-88) THIS FORM MUST BE ACCOMPANI BY A FACIUTY/SITE APPLICATION, FORM 'A',UNLESS A'wARENT FORMA' MAS BEEN FILED <br /> DATA PROCESSING COPY 712 <br />