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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `B': TORAGE TANK PROGRAM <br /> TANK A PLICATION INFORMATION ° <br /> COMPLET ORM W H THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑7,P MANENTLY CL <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE rl;K W-11 <br /> TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES 0 NO "7 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY ) <br /> A. OWNERS TANK ID# 6 q B. MANUFACTURED BY: <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: <br /> Il. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. 00 <br /> A. ❑ i MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL Co <br /> ❑ 3 CHEMICAL PRODUCT [el"OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS <br /> ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN Q f-WASTE ❑ 7 METHANOL E 99 OTHER(DESCRIBE IN ITEM D.BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# �f C.A.S.It: <br /> All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN SOX A,B,C,&D <br /> A.TYPE Of 1 UBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER F--] 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER <br /> i STEEL/IRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK ❑ 5 CONCRETE F-]6 POLYVINYLCHLORIDE F17 ALUMINUM E]8 100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER <br /> ❑ <br /> C. INTERIOR 1 RUBBER LINED ❑2 0 LINING ❑3 EPDXY LINING ❑4 PHENOLIC UNING <br /> LINING ❑5 GLASS LINING P116'UNLINED ❑ 95 UNKNOWN <br /> ❑ISLINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER <br /> D.CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TARORASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑5 CATHODIC PROTECTION 1 NONE ❑95 UNKNOWN ❑99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDE ROUND,BOTH IF APPLICABLE <br /> A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B.CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLED A V 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) A U 4 FIBERGLASS PIPE <br /> C. MATERIAL A5 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 /> )Opt <br /> S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> )O P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED( O/YR) 2. ESTIMATED OU NTITY OF 3. WAS TAN FILLED WITH <br /> SUBSTANCE ING IN GALLONS INET IAL? E]YES [:] NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF P JURY,AND TO THE BEST OF MY KNOWLED E,1S TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> 6b1 I' 4 Q-oo <br /> —R4 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVE BY ME PHONE x WITH AREA CODE <br /> R-�S Z2 !.� <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK k PERMIT AMOUNT SURCHARGE AMT. PEE CODE `:EIPT# BY: <br /> FORM B(3-7-88) THIS FORM MUST BE ACCOMPAN198 A FACILITY/SITE APPLICATION, FORM `A',UNLESS ARENT FORMA' HAS BEEN FILED <br /> DATA C n, 0V. --- -- - - — --- <br />