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T A <br /> STATE OF CALIFORNI& NK WATER RESOURCES CONTROARD <br /> FORM B': UNDERGROUND STORAGE TAPRO RAM ' <br /> TANK TANK PERMIT APPLICATION INFORMATION ro <br /> CO PLETE A SEPARATE FORM WITH THE FOLLOWIN INFORMATION FOR EACH TANK. - z <br /> Ito <br /> MARK ONLY 1 NEW PERMIT F_�3 RENEWAL PERMIT RANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM [-] 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE D B TANK REMOVED / <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: S FARM TANK-YES ED] NO (� <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY / ha <br /> A. OWNERS TANK ID# .-a G7 B. MANUFACTURED BY: 7iC/K 0) <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: <br /> II. TANK qONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. U/1 MOTOR VEHICLE FUEL F__] 2 PETROLEUM B. C. Vl UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT 4 OIL /, PRODUCT ❑ 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> ❑ 5 HAZARDOUS 80 EMPTY ❑95 UNKNOWN 2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAMEOF J 'a <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# 'V/ • C.A.S.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A TYPE OF © I DO BLEWALLEO ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM SINGLEWALLED ❑4 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEEUIRON 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK 5 CONCRETE 6 POLYVINYLCHLORIDE 7 ALUMINUM 8 100%METHANOL COMPATIBLE FAP <br /> MATERIAL <br /> ❑ 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> C. INTERIOR <br /> I RUBBER LINED 2 ALKYD LINING E:] 3 EPDXY LINING 4 P NOUC LINING <br /> LINING F-15 GLASS LINING �6 UNLINED UNKNOWN <br /> IS LINING MATERIAL COMPATIBLEWRH IDD%METHANOL? ❑YES ❑ NO 99 OTHER <br /> D. CORROSION ❑ 1 POLYETHUENEWRAP 2 TARORASPHALT L]3 V LWRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION D 5 CATHODIC PROTECTION 91 NONE UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A a <br /> 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 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE 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 A1095 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 /> ]Y y� P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br />�T J P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER <br /> VI. 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 /> SUBSTANCE REMAINING IN INERT MATERIAL? YES � NO <br /> GALLONS <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# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> U I d = 100101 <br /> LCNECK# <br /> AGENCY FACILITY ID M _ APPROVED B NAME YR PHONE#WITH AREA CODE <br /> R S S PERMIT APPROVAL DATE/ 3PERMIT EXPIRYA/TI`ON DATE <br /> PERMIT AMOUNT SURCHARGE ANT. FEE CODE RECEIPT# BY: <br /> FORMB(6-29-88) THIS FORM MUST BE ACCOMPANIE YAFACILITY/SITE APPLICATION, FORM 'A',UNLESS A RRENT FORMA' HASBEENFILED <br /> DATA PROCESSING COPY <br />