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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> OdRM 'B': UNDERGROUND STORAGE TANK PROGRAM <br /> TANK TANK PERMIT APPLICATION INFORMATION i A <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY rZJNEW PERMIT F1 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION F-1 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE F-]8 TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED:,! � <br /> _1_ (-7_",& FARMTANK-YES O NO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKN04N—SO SPECIFY <br /> IA. OWNERS TANK ID# B. MANUFACTURED BY: <br /> C.YEAR INSTALLED F-=:;� D. TANK CAPACITY IN GALLONS:- — O <br /> 11. TANK CONTENTS IF(A.11),IS MARKED,COMPLETE ITEM C.IF(A.11),IS NOT MARKED,COMPLETE ITEM D. F-4 <br /> A. [glrMOTOR VEHICLE FUEL 2 PETROLEUM B. C. [ UNLEADED r-j 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT 4 OIL -4-moDuCT 0 4 GASAHOL F—]5 JET FUEL <br /> EQ E16 AVIATION GAS <br /> 5 HAZARDOUS 80 EMPTY [:]95 UNKNOWN 2 WASTE 7 METHANOL 0 99 OTHER(DESCRIBE IN ITEM 0,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S. <br /> xill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C.a D <br /> A.TYPE OF [�J�BLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 0 2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> D.TANKF-1 I S%WIRON 2 STAINLESS STEEL EQt"ERGLASS 4 WE CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL F-1 5 CONCRETE F-1 6 POLYVINYLCHLORIDE F-] 7 ALUMINUM 8 i00%mErHANoL COMPATIBLE FRP <br /> 9 BRONZE F] 10 GALVANIZED STEEL [:)95 UNKNOWN 99 OTHER <br /> C.INTERIORF-1 1 RUBBER LINED F-12 ALKYD LINING 3 EPDXY LINING F-�4 PHENOLIC LINING <br /> LINING F--j 5 GLASS LINING lqftNUNED �95 UNKNOWN <br /> E]IS LINING MATERIAL COMPATIBLE WITH i00%METHANOL? YES [::] NO [:]99 OTHER <br /> D.CORROSION ❑ I POLYETHLENE WRAP [:]2 TAR OR ASPHALT . F-1 3 VINYL WRAP [D-rrBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION E]91 NONE 0 95 UNKNOWN E]99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A.SYSTEM TYPE A U I SUCTION A PRESSURE A U 3'GAAVITY A U 99 OTHER <br /> CONSTRUCTION A U I SINGLE WALLED A gr-i DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A 6C:?FIBERGLASS PIPE <br /> C.MATERIAL "A U 5 AL I OMINUIM A U 6 CONCRETE A U 1STEEL CLAD W/FRP ti A U 8 100%METHANOL CqMPATIBLE FRP <br /> A Us 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 DETECT16M SYSTEM MUST BE CIRCLED. <br /> P 8 1VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS 4 ELECTRONIC MONITOR P 3 5 GROUNDWATER MONITORING WELLS <br /> P 8 6 PRECISION TESTING P 3 7 PRESSURE TESTING P 5 91 NONE P 3 95 UNKNOWN 8 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE , <br /> 1.ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF —T-3-WAS TANK FILLED WITH <br /> SUBSTANCE,REMAINING IN INERT MATERIAL? F-1 YES 0 NO <br /> t GALLONS <br /> THIS FORM HAS BEEN COMPLETED PENALTY OFPERJUF)�,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> [APPLICANT"A RINT 1111NATIRE) DATE <br /> LOCAL AGENCY USE ONLY <br /> - <br /> COUNTY#..—" vi msDiCTION�r AGENCY# FACILITY 10# TANK ID d <br /> CURRENT LOCAL AGENCY FACILITY 10 0 APPROVED BY NAME PHONE 0 WrrH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK# PERMIT AMOUNT SURCHARGE ANT. FEE CODE RECEIPT 0 DY: <br /> FORM s(3-7-8s) THIS FORM MUST BEACCOMPAN,I&MA Fwumsm APPLICATION, FORM'A,UNLESS RENT FORM`A' HAS BEEN FILED <br /> LOCAL AGENCY COPY <br />