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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'B': UNDERGROUND STORAGE TANK PROGRAM <br /> TANKTANK PERMIT APPLICATION INFORMATION <br /> TANK. <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH �" o <br /> MARK ONLY ❑ 1 NEW PERMIT F-1 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSTfANK <br /> ONE ITEM F-] 2 INTERIM PERMIT F-14 AMENDED PERMIT 0 6 TEMPORARY TANK CLOSURE '8 TANK REMOVED 11 <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: 7Y J,�/In,. FARM TANK-YES❑ NO W <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK IDN 3 I B. MANUFACTUREDBY: <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 4,9,05 <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A 71 MOTOR VEHICLE FUEL F-1 2 PETROLEUM B. C. ';�'�UNLEADED 2 LEADED ❑ 3 DIESEL <br /> 3 CHEMICAL PRODUCT 0 4 OIL [El1 PRODUCT ❑4 GASAHOL 5 JET FUEL Ej 6 AVIATION GAS <br /> 05 HAZARDOUS ❑ 80 EMPTY 0 95 UNKNOWN 2 WASTE O 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF / A <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# WA <br /> C.A.S. <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&0 <br /> A. TYPE OF ❑/1 DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER 95 UNKNOWN <br /> SYSTEM r `SINGLE WALLED F-1 4 SECONDARY CONTAINMENT 99 OTHER <br /> Cll�1'STEEL/IRON F-1 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS 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 RUBBER UNED F-1 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> C. INTERIOR ❑ 5 GLASS LINING D'rUNUNED 95 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES 0 NO � OTHER qeL✓�J <br /> D. CORROSION ❑ 1 POLYETHLENEWRAP 2 TARORASPHALT 0 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 0 5 CATHODIC PROTECTION 91 NONE r�l95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IFA:x GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A.SYSTEM TYPE A U i SUCTION A 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 DOUBLEWALLED A U 3 LINEDTRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POCYVINIYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C.MATERIAL A U S ALUMINUM A 3L>6 CONCRETE A U 7 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL ACV95 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 /> A )T P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS <br /> W P S I PRECISION TESTING P S 7 PRESSURE TESTING 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> L ESTIMAT DATE LAST USED(MO/YR) 2. ESTIMA D QUANTITY OF 3, STANK FILLED WITH <br /> 0) SU T E REMAINING IN GALLONS ,1 FST MATERIAL? Ej YES ONO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY bF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> [� o v 0 10 2 <br /> CURPENT LOCAL rCY FA ITY ID# APPR VED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE ('�'/�' FERMI EXPIRATION DATE <br /> CHECK# PERMIT AMOUNT CHARGE AMT. FEE CODE RECEIPT# BY: <br /> FORM B(6-29,9a) THIS FORM MUST BE ACCOMPANIED B FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CVWNT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />