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STATE OF CALIFORN WATER RESOURCES CONTROARD <br />FORM'B': <br />UN GROUND STORAGE TANK PR RAMo <br />TANK TANK PERMIT APPLICATION INFORMATION <br />COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br />MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT P?l CHANGE OF INFORMATION 7 PERMANENTLY C D TAN <br />ONE ITEM 2 INTERIM PERMIT F-]4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED l 2 <br />FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK -YES NO <br />I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY <br />A. OWNERS TANK ID # B. MANUFACTURED BY: <br />C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: ao0 <br />II. TANK CONTENTS IF (A.114S MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. <br />A 1 MOTOR VEHICLE FUEL 2 PETROLEUM <br />B. <br />C• F 1 UNLEADED 2 LEADED 3 DIESEL <br />3 CHEMICAL PRODUCT 4 OIL <br />PRODUCT <br />4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br />5 HAZARDOUS 80 EMPTY [::] 95 UNKNOWN <br />2 WASTE <br />7 METHANOL CK OTHER (DESCRIBE IN ITEM D, BELOW) <br />D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF <br />HAZARDOUS SUBSTANCE STORED & C.A.S. # sle� C.A.S. t jpo d Zr7 <br />III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D <br />A. TYPE OF <br />i OUBLE WALLED <br />3 SINGLE WALLED WITH EXTERIOR LINER <br />95 UNKNOWN <br />SYSTEM <br />k2 SINGLE WALLED <br />4 SECONDARY CONTAINMENT <br />99 OTHER <br />A(,V <br />1 STEEL/IRON <br />2 STAINLESS STEEL <br />❑ 3 FIBERGLASS <br />❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br />B. TANK <br />5 CONCRETE <br />6 POLYVINYLCHLORIDE <br />❑ 7 ALUMINUM <br />8 100% METHANOL COMPATIBLE FRP <br />MATERIAL <br />9 BRONZE <br />10 GALVANIZED STEEL <br />❑ 95 UNKNOWN <br />99 OTHER <br />3 POLYVINYL CHLORIDE (PVC) A U <br />1 RUBBER LINED <br />2 ALKYD LINING <br />F-]3 EPDXY LINING <br />F-14 PHENOLIC LINING <br />C. INTERIOR <br />LINING <br />F� 5 GLASS LINING <br />NLINED <br />U <br />D P5 <br />8 100% METHANOL COMPATIBLE FRP <br />[:] SLININGMATERIALCOMPATIBL)WIH(100%METHANOL? <br />YES 0 NO <br />��OTHERWL'4"'W <br />D. CORROSION <br />❑ 1 POLYETHLENE WRAP <br />2 TAR OR ASPHALT <br />F-1 3 VINYL WRAP <br />4 FIBERGLASS REINFORCED PLASTIC <br />PROTECTION <br />❑ 5 CATHODIC PROTECTION <br />❑ 91 NONE <br />95 UNKNOWN <br />99 OTHER <br />IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE <br />V. <br />A. SYSTEM TYPE <br />A <br />o 1 SUCTION <br />A U 2 PRESSURE <br />A U <br />3 GRAVITY A U 91 NONE <br />A U 95 UNKNOWN A U 99 OTHER <br />B. CONSTRUCTION <br />A(,V <br />1 SINGLE WALLED <br />A <br />U 2 DOUBLE WALLED <br />A <br />U <br />3 LINED TRENCH A U 91 NONE <br />A U 95 UNKNOWN A U 99 OTHER <br />A <br />U 1 STEEL/IRON <br />A <br />U 2 STAINLESS STEEL <br />A <br />U <br />3 POLYVINYL CHLORIDE (PVC) A U <br />4 FIBERGLASS PIPE A U 91 NONE <br />C. MATERIAL <br />A <br />U 5 ALUMINUM <br />A <br />k6 CONCRETE <br />A <br />U <br />7 STEEL CLAD W/FRP A U <br />8 100% METHANOL COMPATIBLE FRP <br />A <br />U 9 GALVANIZED STEEL A <br />5 UNKNOWN <br />A <br />U <br />99 OTHER <br />LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br />P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS <br />Pah 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. ESTIMA ED DATE LAST USED (MO/YR) <br />n <br />V� <br />2. ES IMATED QUANTITY OF <br />TANCE REMAINING IN <br />I <br />GALLONS <br />3, WAS ANK FILLED WITH <br />NE ATERIAL? <br />YES <br />D NO <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />APPLICANT'S NAME (PRINTED & SIGNATURE) DATE <br />I noel ArFNCV IIAF nNLV <br />JURISDICTION # <br />I 1 11 <br />AGENCY # <br />EI I I <br />FACILITY ID # <br />IDU t !b <br />TANK ID #lE <br />�ol U <br />AGENCY FACS ID # <br />Jo vo <br />3 `(1 <br />E <br />A ROVE Y N E V <br />PHONE #WITH AREA CODE <br />PERMIT APPROVAL DATE <br />ERMIT EXPIRATION DATE <br />PERMIT AMOUNT .MLSURCHARGE <br />AMT. <br />FEE CODE RECEIPT # <br />BY: <br />FORM B (6-29-88) THIS FORM MUST BE ACCOMPANIEUM A FACILITY/SITE APPLICATION, FORM 'A', UNLESS A CURRENT FORM `A' HAS BEEN FILED <br />DATA PROCESSING COPY <br />z <br />10 <br />S <br />