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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> ' FORM 'B': UNDERGROUND STORAGE TANK PROGRAM ` <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY D 1 nEW PERMIT Fj 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM F-1 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE F-�8 TANK REMOVED t_ <br /> I <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: 6 T, �0 0 FARM TANK-YES NO <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWd—SO SPECIFY to <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 2 W <br /> 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. f'a <br /> A. -KZTOR VEHICLE FUEL 2 PETROLEUM B. C. 1 UNLEADED �2-tEAOED 3 DIESEL (� <br /> AIN <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 NAME OF <br /> HAZARDOUS SUBSTANCE STORED 8.C.A.S.# C.A.S.#: <br /> x111. TANK CCONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF E]; `OUBLE WALLED F'-]3 SINGLE WALLED WITH EXTERIOR LINER F-]95 UNKNOWN <br /> SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT E]99 OTHER <br /> 1 STEEL/IRON E:]2 STAINLESS STEEL Ej j W BERGLASS �4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANG( � <br /> MATERIAL 5 CONCRETE [—]6 POLYVINYLCHLORIDE F-17 ALUMINUM F--j 8 100%METHANOL COMPATIBLE FRP <br /> ❑9 BRONZE E] 10 GALVANIZED STEEL [—]95 UNKNOWN 99 OTHER <br /> C.INTERIOR 1 RUBBER LINED [:]2 ALKYD LINING F-13 EPDXY LINING 4 PHENOLIC LINING <br /> LINING ❑5 GLASS LINING 1NUNED 95 UNKNOWN <br /> 0 IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? E:]YES [:]NO 99 OTHER <br /> D.CORROSION ❑1 POLYETHLENE WRAP 2 TAR OR ASPHALT F-�3 VINYL WRAP �GLASS REINFORCED PLASTIC <br /> PROTECTION [—] 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN Ej 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 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A dr,,i DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A419 FIBERGLASS PIPE <br /> C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 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 DETECTION SYSTEM MUST BE CIRCLED. <br /> P 8 1VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P 8 7 PRESSURETESTING 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 USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E:]YES [:]NO <br /> THIS FORM HAS BEEN C MPLET D UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLIC TS N (PRI 8 SIGNATURE) /V� / DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> ffm / I sg <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BYN PHONE#WITH AREA CODE <br /> r`. <br /> I PEAMtT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE Q <br /> 1 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: L <br /> tr�. FORM B(3-7-88) THIS FORM MUST BE ACCOMPANI&-4 A FACILITY/SITE APPLICATION, FORM `A',UNLESS A`�.RENT FORD-N HAS BEEN FILED <br /> \�1 -� DATA PROCESSING COPY <br />