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STATE OF CALIFORN WATER RESOURCES CONTR OARD <br /> FORM `B': UNDAGROUND STORAGE TANK PR RAM <br /> TANK TANK PERMIT APPLICATION INFORMATION io <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. `�•••o ' <br /> MARK ONLY <br /> I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION PERMANENTLY CLOSED TANK ) <br /> ONE ITEM E]2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE B TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: D <br /> C( Q FARM TANK-YES Ef NO � {--�• <br /> I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY Oa <br /> W <br /> [:AOW:NERS TANK IDN B.MANUFACTURED BY:C.YEARISTALLED D,TANK CAPACITY IN GALLONS: <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. Vi MOTOR VEHICLE FUEL 2 PETROLEUM B. C. El 1 UNLEADED 2 LEADED E]3 DIESEL <br /> 3 CHEMICAL PRODUCT 4 OIL PRODUCT ❑4 GASAHOL Ej 5 JET FUEL 0 6 AVIATION GAS <br /> 5 HAZARDOUS 80 EMPTY 0 95 UNKNOWN ❑2 WASTE E]7 METHANOL 0 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D.IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED B CA.S.N C.A.S.N: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,0,C,&D <br /> A TYPE OF ❑I OOUBLEWALLED 3 SINGLEWAILEOWITHEXTEFKIILINER UNKNOWN <br /> SYSTEM Ej 2 SINGLE WALLED 04 SECONDARY CONTAINMENT [:]99 OTHER <br /> I STEEUIRON [-]2 STAINLESS STEEL 3 FIBERGLASS Ej 4 STEEL CLADW/FIBERGLASS REINFORCEDPUSVC <br /> B.TANK <br /> MATERIAL 5 CONCRETE E]6 POLYVINYLCHLORIDE 1 ALUMINUM 8 1W%METHANOL COMPATIBLE FRP <br /> 09 BRONZE E]10 GALVANIZED STEEL ,UNKNOWN 99 OTHER <br /> C.INTERIOR Ej I RUBBER LINED 2 ALKYO LINING 3 EPDXY LINING E]4 PHENOLIC LINING <br /> LINING ❑S GLASS LINING 6 UNLINEDUNKNGWN <br /> [:]IS LINING MATERIAL COMPATIBLE M7H 100%METHANOL? YES E]NO DTHER �D.CORROSION ❑I POLYETHLENEWRAP 0 2 TAR OR ASPHALT 3N LWRAP 4 F18ERGMFLEINFORCEOPLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION [:j 91 NONE KNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND,BOTH IFAPPLICABLE <br /> A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE U 5 UNKNOWN A U 99 OTHER <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 5 UNKNOWN—T U 99 OTHER <br /> A U I STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYLCHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE <br /> C.MATERIAL A U 5 ALUMINUMA 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL U 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 /> 3 1 VISUAL CHECK P 3 2 INVENTORY RECONCILIATION P ELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS <br /> P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P 3 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1.ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF 3,WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? YES [-]NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED b SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY ID N �. (J TANK ID N <br /> mil 11 11 1 1 1 1 Ll - b+—!**51 Olo lo <br /> CURRENT LOCA ENCY FACILITY IDM /, / /L r�� ]APPR�DVBYN E PHONE Y WITH AREA CODE <br /> PERMIT NUMBER J U ly�l- PERMIT APPROYAL DAT PERMIT EXPIRATION DATE <br /> CHECK PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT a gy; <br /> FORM D(6 29.6a) THIS FORM MUST BE ACCOMPANIED BY A FA /SITE APPLICATION, FO R M'A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />