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4 SE''`iui�'T,•E' . <br />STATE OF CALIFORNI WATER RESOURCES CONTRARD <br />r: _ <br />FORM `B': UND GROUND STORAGE TANK PRO ,4M `� E <br />TANKTANK PERMIT APPLICATION INFORMATION <br />(�' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z <br />MARK ONLY Eal"NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION El 7 PERMANENTLY CLOSED TANK <br />ONE ITEM [:] 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORRARYY TANK CLOSURE 0 8 TANK REMOVED D/ <br />FACILITY/SITE NAME WHERE TANK IS INSTALLED: ! S"C� �{/• �A� R`.ylfw 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: �S6 <br />II. 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 <br />B.C. <br />1 UNLEADED 2 LEADED 3 DIESEL <br />3 CHEMICAL PRODUCT F-]4 OIL <br />PRODUCT <br />4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br />5 HAZARDOUS 80 EMPTY 0 95 UNKNOWN <br />2 WASTE <br />El 7 METHANOL 99 OTHER (DESCRIBE IN ITEM D, BELOW) <br />/ <br />D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF /)/14 <br />HAZARDOUS SUBSTANCE STORED & C.A.S. # C.A.S. #: ILA <br />/Lr 14 <br />III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D <br />IV. <br />A. TYPE OF <br />1 DOUBLE WALLED <br />❑ 3 SINGLE WALLED WITH EXTERIOR LINER <br />95 UNKNOWN <br />SYSTEM <br />2 SINGLE WALLED <br />4 SECONDARY CONTAINMENT <br />99 OTHER <br />B. CONSTRUCTION <br />1 STEEL/IRON <br />2 STAINLESS STEEL <br />[�J'3 FIBERGLASS <br />F-1 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br />B. TANK <br />F --ll 5 CONCRETE <br />El 6 POLYVINYLCHLORIDE <br />F--] 7 ALUMINUM <br />8 100% METHANOL COMPATIBLE FRP <br />MATERIAL <br />9 BRONZE <br />10 GALVANIZED STEEL <br />[:] 95 UNKNOWN <br />99 OTHER <br />4 FIBERGLASS PIPE A U 91 NONE <br />1 RUBBER LINED <br />2 ALKYD LINING <br />El 3 EPDXY LINING <br />F-14 PHENOLIC LINING <br />C. INTERIOR <br />LINING <br />❑ 5 GLASS LINING <br />6 UNLINED0 <br />8 100% METHANOL COMPATIBLE FRP <br />95 UNKNOWN <br />A <br />IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? <br />YES [:] NO <br />[-] 99 OTHER <br />D. CORROSION <br />❑ 1 POLYETHLENE WRAP <br />2 TAR OR ASPHALT <br />❑ 3 VINYL WRAP <br />4 FIBERGLASS REINFORCED PLASTIC <br />PROTECTION <br />E] 5 CATHODIC PROTECTION <br />91 NONE <br />95 UNKNOWN <br />99 OTHER <br />NININU INFUKMA 1 IUN CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE <br />A. SYSTEM TYPE <br />At'V <br />SUCTION <br />A <br />U 2 PRESSURE <br />A <br />U 3 GRAVITY A U 91 NONE <br />A U 95 UNKNOWN A U 99 OTHER <br />B. CONSTRUCTION <br />A <br />U 1 SINGLE WALLED <br />A <br />DOUBLE WALLED <br />A <br />U 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 />—02 <br />U 2 STAINLESS STEEL <br />A <br />U 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 />U 6 CONCRETE <br />A <br />U 7 STEEL CLAD W/FRP A U <br />8 100% METHANOL COMPATIBLE FRP <br />AMOUNT <br />A <br />U 9 GALVANIZED STEEL <br />A <br />U 95 UNKNOWN <br />A <br />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 S 1 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 DATE LAST SED (MO/YR) <br />2. ESTIMATED QUANTITY OF <br />AGENCY # <br />3, WAS TANK FILLRD WITH <br />TID # <br />I <br />SUBSTANC R M DING IN <br />I olo I/ Is- I � 1� I <br />INERT M T`11/LA <br />0 YES <br />E] NO <br />APPROVED BY NAME/ <br />7`-+ <br />GALLONS <br />of -i <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 />LOCAL AGENCY USE ONLY <br />COUNTY # <br />JURISDICTION # <br />AGENCY # <br />FACILITY ID # <br />TID # <br />I <br />E[ <br />I olo I/ Is- I � 1� I <br />F -/g Fo1c) [d <br />CURRENT LOCAL AGENCY FACILITY ID # <br />APPROVED BY NAME/ <br />PHONE # WITH AREA CODE <br />6 -3z( <br />PERMIT NUMBER <br />PERMIT APPROVAL JDATE <br />PERMIT EkPIRAflON DATE <br />CHECK #PERMIT <br />AMOUNT <br />SURCHARGE AMTf <br />FEE CODE RECEIPT # <br />BY: <br />FORM B (6-29-88) THIS FORM MUST BE ACCOMPANIEW A FACILITY/SITE APPLICATION, FORM 'A', UNLESS A'=RENT FORM `A' HAS BEEN FILED <br />DATA PROCESSING COPY <br />