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1`STATE OF CAL.IFORNIA ;;, ,WATER RESOURCES CONTROL ARD
<br /> to F®RM 'B' +, y UNDERGROUND STORAGE TANK,PROGi(AM tl`
<br /> ;'G: TANK PERMIT APPLICATION INFORMATION ,._
<br /> # + TAN K I COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK.
<br /> i >E
<br /> r 1 NEW PERMIT '}'-" 3 RENEWAL PERMIT GRANDE OF INFORMATION -❑7 PERMANENTLY CLOSED TANK
<br /> I MARK ONLY,< ❑ , ❑
<br /> 4,ONE ITEM ❑2"INTERIM PERMR' i ', ❑{AMENDED PERMIT _ ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED -
<br /> s
<br /> y FACILITY/SITE NAME WHERE TANK IS INSTALLED: q f-Seo ,�, ` - FARM TANK-YES❑ NO Z
<br /> CIIYTANK DESCRIPTION 'COAAPLETE ALL ITEMS LIF UNKNOWN SO SPEGFY 10 '
<br /> A.-OWNERS TANK IDR ';' B. MANUFACTURED BY: QLdNs-•COY,n • -;
<br /> C,.YEAR.INSTALLED D.DTANK CAPACITY IN GALLONS:
<br /> .. � .
<br /> 7 11:TANK CONTENTS , . IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D.
<br /> A 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM - B. C. ❑ 1 UNLEADED ❑2 LEADED 3 DIESEL
<br /> s ©3 CHEMICAL PRODUCT -`. ❑ 1 OIL ';' PRODUCT ❑{GASAHOL _, ❑5 JET FUEL . ❑6 AVIATION GAS
<br /> 4 +, �5HAZAR000S s 2g E] 80 ❑.95 UNKNOWN .❑2WASTE ❑]METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW)
<br /> ' + 02 IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF -
<br /> I ! . HAZARDOUS SUBSTANCE STORED 6 CA.S R - C.A.S.W
<br /> Ill. TANK CONSTRUCTION.: MARK ONE ITEM ONLY IN BORA,B,C,&0 -
<br /> A.TYPE OF ❑ I BLE WALLED ,.:-Q.3 SNGlE WALLFDWRH EXTENOfl UNFA ❑95 UNKNOWN .
<br /> SYSTEM ,rn�1t.`. 2 SINGLE WALLED ,� ❑/SECONDARYCONTAINMENT _ ❑99 OTHER
<br /> IT v
<br /> ❑ 1,5TEEL/IRON . ;'❑2 STAINLESS STEEL.. 3 FlBETIGIA53 /STEELCLAD WIFlBFAGIA55 REINFORCED RUSTIC .�
<br /> is B,TANK u1 ._..❑ 5 CONCRETE .❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 100AMETFUHOLOOMPATIBLEFRP
<br /> s. - ..�;:❑9 BRONZE 10 GALVANIZED STEN: ❑95 UNKNOWN •: '❑99 OTHER
<br />'4
<br /> ❑ 1 RUBSERUNED ❑ KYD
<br /> 2 AIUNING ❑3 EPDXY LINING E]/PHENOUCUNING
<br /> s C,INTERIOR <
<br /> Ii LINING * ❑5 Gm LINING .,..:f 6 UNUNED, ❑95 UNKNOWN
<br /> rt 'rt'r ,�❑B UNNG MATERML COMPATIBLE WITH 100%METHANOL? E]YES 0 N-: '❑.99 OTHER
<br /> 6T4 D CORROSION ,❑ 1 ROLYETMIENEWHPP ❑2 MORASPMALT ❑3VINYL WRAP - ❑/FIBERGULRS REINFORCED RUSTIC
<br /> PROTECTION,._❑5 GTHODIC PROTECTION` .91 NONE ❑95 UNKNOWN ❑99 OTHER
<br /> Id PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE
<br /> ' `KSYSTEM TYPE^' >`:A 1 SUCTION A U-2 PRESSURE #'U 3 GRAVITY' A U 99 OTHER.
<br /> 1 ,1.
<br /> B CONSTRUCTION 'A;U. 1 SNGLE WALLED '`,A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 5 UNKNOWN A U 99 OTHER
<br /> ,A'U'I STEELARON.''. A U 2 STAINLESS STEEL -A U .3 POLYVINYL CHLORIDE(PVC) A U O FIBERGLASS PIPE _ 9
<br /> C.MATERIAL`Ip�'a ASU I5 ALUMINUM A U 6 CONCRETE A U. 7STEEL CUD W/FRP A U 8100%METHANOL COMPATIBLEFRP
<br /> A,U;9 GALVANIZED STEEL A 1995 UNKNOWN b.0 89 OTHER
<br /> 1r V. LEAK DETECTION SYSTEM 1.CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED.
<br /> y� P`SB 1 VISUAL.CHECK I:''.. P 8 2 INVENTORY RECONCILIATION, P'8 3 VA00SE WELLS P 8 4 ELECTRONIC MONITOR P'S S GROUND WATER MONITORING WELLS
<br /> T j -F 8 PRECISION.TESTING P:8 7.PRESSURE TESTING -P S 91 NONEP, B 95 UNKNOWN 'P`S 99 OTHER
<br /> VI ;INFORMATION ON.TANK.PERMANENTLY CLOSED IN PLACE
<br /> p ,�,° 7;ESTIMATED DATE UST USED(MOLAR) '2. ESTIMATED QUANTITY OF3. WAS TANK FILLED WITH
<br /> SUBSTANCE REMAINING IN : �LONS INERT MATERIAL? ❑YES ❑ NO
<br /> u I v ''NTHIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. a
<br /> APPLICANTS NAME(PRINTE08SIGNATURE) DATE
<br /> I '�"LOCAL'AGENCY USE ONLY
<br /> b 1;J,:'COUNTY R ,,`; JURISDICTION R F AGENCY R. FACILITY IDN -. TANK ID R
<br /> ry1
<br /> r,..
<br /> CURRENT LOCAL AGENCY FACILITY IDR APPPRROVED BBY,.HAMW PHONE#WITHAREA CODE
<br /> PERMIT NUMBER PERMTTAPPROVALDA '+O PERMIT E%PIRATON DATE
<br /> Y}
<br /> CHECK# a PERT AMOUNT SURCHARGE AMT. _ FEE CODE
<br /> WREC;PT
<br /> I- BY:
<br /> FORM B(3 708) THIS FORM MUST BE ACCOMPAMeO BT AFACILITYISITE APPUCATION, FORM 'A',UNLESf UR NT FORMA' HAS BEEN FILED
<br /> .; PROCESSING'DATA- COPY F `
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