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STATE OF CALIFORN WATER RESOURCES CONTR OARD <br /> FORM `B': UNI GROUND STORAGE TANK PROGRAM ;, . <br /> TANK PERMIT APPLICATION INFORMATION <br /> TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY n ' NEW PERMIT F-] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOW ANK <br /> ONE ITEM 2 INTERIM PERMIT F-14 AMENDED PERMIT El 6 TEMPORARY TANK CLOSURE 0 8 TANK REMOVED 101 <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: + FARM TANK-YES D NOjo <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY <br /> A. OWNERS TANK ID# Q 1 B. MANUFACTURED BY: <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: lo <br /> �(aD <br /> A <br /> ll. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. F-s <br /> A. 1 MOTOR VEHICLE FUEL F-1 2 PETROLEUM B. C. Rl UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT 4 OIL fJ ' PRODUCT E]4 GASAHOL 5 JET FUEL E]6 AVIATION GAS <br /> ❑ 5 HAZARDOUS 80 EMPTY [::] 95 UNKNOWN 2 WASTE 0 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# VIA C.A.S.#: <br /> xlll. TANK CONSTRUCTION MARK ONE IT M ONLY IN BOX A,B,C,&D <br /> A.TYPE OF ❑ 1 DOUBLE WALLED F-1 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM IJ 2 SINGLE WALLED D 4 SECONDARY CONTAINMENT 99 OTHER <br /> Eerl STEEL/IRON ❑2 STAINLESS STEEL F-13 FIBERGLASS 4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK <br /> MATERIAL F-15 CONCRETE [_]6 POLYVINYL CHLORIDE F-]7 ALUMINUM E]8 100METHANOL COMPATIBLE FRP <br /> 9 BRONZE E] 10 GALVANIZED STEEL [:]95 UNKNOWN 99 OTHER <br /> C.INTERIOR 1 RUBBER LINED [—]2 ALKYD LINING �3 EPDXY LINING 4 PHENOLIC LINING <br /> LINING ❑5 GLASS LINING Fk6 UNLINED E]95 UNKNOWN <br /> 0 IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? E]YES ❑ NO El 99 OTHER <br /> D.CORROSION ❑ 1 POLYETHLENE WRAP F-�2 TAR OR ASPHALT 3VIVINYL WRAP Ej 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION D 91 NONE �95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A.SYSTEM TYPE A Wl SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 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) A U 4 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 GALVANIZEDSTEEL A 095 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 /> P1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE" P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED D E ST USED(MO/YR) 2. ESTIMATED QUIANTITY OF 3.WAS TANK ILLED WITH <br /> SUBST RIMANING IN INETATR L? ❑YES [:] NO <br /> GALLONS <br /> THIS FOR HAS BEEN COMPLETED UNDER PENALTY OF P JURY,AND TO THE BEST OF MY KNOWLED 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 /> op101010111 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPRO ED BYA E [� PHONE#WITH AREA CODE <br /> OY <br /> PERMIT NUMBER P IT APPROVAL D PERMIT EXPIRATION DATE <br /> CHECK# PERMIT AMOUNT SURCHARGE AMt. FEE CODE RECEIPT# BY: <br /> FORM B(3-7-88) THIS FORM MUST BE ACCOMPA BYA FACILITY/SITE APPLICATION, FORM `A',UNI ES IRRENT FORMA' HAS BEEN FILED <br /> DATA. PROCESSJNC COPY <br />