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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br />FORM 'B': UNDERGROUND STORAGE TANK PROGRAM <br />TANK PERMIT APPLICATION INFORMATION <br />COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br />TANK <br />MARK ONLY ❑ i NEWPERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYCLOSED TANK <br />ONE ITEM ❑ 2 INTERIM PERMIT ❑ A <br />4 AMENDED PERMIT ❑6TEMPGRA TANK CLOSURE ❑STANK REMOVED <br />�`}v FARM TANK -YES NO <br />FACILITY/SITE NAME WHERE TANK IS INSTALLED: d <br />4, pre, <br />I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN — SO SPECIFY <br />PYEARI <br />TANK ID# B. MANUFACTURED BY: GCC <br />D. TANK CAPACITY IN GALLONS: Q Q <br />TALLED �L <br />II. TENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A,1), IS NOT MARKED, COMPLETE ITEM D. <br />RC. ❑ 1 UNLEADED ❑ 2 LEADED EATISEL <br />OTOR VEHICLE FUEL ❑ 2 PETROLEUM Lr�l,l/HEMICAL PRODUCT ❑ 4 OILPRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL❑ 6 AVIATION GAS <br />AZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN REM D, BELOW) <br />D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF C.A.S. N: <br />HAZARDOUS SUBSTANCE STORED 8 C.A.S. # <br />TANK CON5THuc I wn MAHK UNC nCW v lA. <br />JURISDICTION # <br />TYPE OF <br />❑ 1 DOUBLE WALLED <br />❑ 3 SINGLE WALLED WITH EXTERIOR LINER <br />95 UNKNOWN <br />❑ 99 OTHER <br />SYSTEM <br />❑ 2 SINGLEWALIEI <br />❑ 4 SECONDARY CONTAINMENT <br />SYSTEM TYPE <br />❑ 1 STEEUBION <br />❑ 2 STAINLESS STEL <br />❑ 3 FIBERGLASS <br />❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED NAS RC <br />B. TANK <br />❑ 5 CONCRETE <br />❑ 6 POLYVINYLCHLORIDE <br />❑ 7 ALWrNUM <br />❑ 81DA METHANOL GOMPATIBLEFRP <br />MATERIAL <br />❑ 9 BRONZE <br />❑ 10 GALVANIZED STEEL <br />[3195 UNKNOWN <br />❑ 99 OTHER <br />A <br />❑ 1 RUBBER UNED <br />❑ 2 ALKYD LINING <br />❑ 3 EPDXY LINING <br />❑ 4 PH INING <br />C. INTERIOR <br />LINING <br />❑ 5 GLASSUNING <br />❑ 6 UNLINED <br />A U <br />UNKNOWN <br />A <br />❑ IS LINING MATERIAL COMPATIBLE <br />MIH 100%METHANOL? <br />❑YES ❑ NO <br />❑ 99 OTHER <br />C. MATERIAL <br />❑ 1 POLYETHLENE WRAP <br />❑ 2 TAB OR ASPHALT <br />❑ 3 VI P <br />❑4 FIBERGLASS REINFORCED PLASTIC <br />FDCORTROSION <br />OECTION <br />❑ 5 CATHODIC PROTECTION <br />❑ 91 NONE <br />95 UNKNOWN <br />❑ 99 OTHBI <br />IV nmwn_!&IV^nAA ATUTAI CIDCLE A mn <br />ARnVE Fnl imn U IF UNDERGROUND. BOTH IF APPLICABLE <br />LE <br />V- LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br />P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P�f, iGTA MONITOR P S 5 GROUNDWATER MONITORING WELLS <br />P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UN (NO P 8 99 OTHER <br />VI- INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br />1. ESTIMATED DATE LAST USED (M07YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH <br />SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑ YES ❑ NO <br />THIS F( <br />-OCAL <br />RM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND C( <br />APPLICANT'S NAME (PRINTED S SIGNATURE) DATE <br />Y <br />YHtG 1. <br />O <br />L" <br />N <br />A <br />N <br />GJi <br />COUNTY# <br />JURISDICTION # <br />AGENCY # FACILITY ID # <br />TANK ID # <br />ail <br />SYSTEM TYPE <br />A U <br />1 SUCTION <br />A U <br />2 PRESSURE <br />A <br />U <br />3 GRAVITY A U 91 NONE <br />A(U 5 UNKNOWN <br />A U 99 OTHER <br />B CONSTRUCTION <br />A U <br />1 SINGLE WALLED <br />A U <br />2 DOUBLE WALLED <br />A <br />U <br />3 LINEDTRENCH A U 91 NONE <br />?U 95 UNK Wf <br />A U 99 OTHER <br />A U <br />1 STEELARON <br />A U <br />2 STAINLESSSTEEL <br />A <br />U <br />3 POLYVINYL CHLORIDE IPVC) A U <br />4 FIBERGLASS PIPE <br />A U 91 NONE <br />C. MATERIAL <br />A U <br />5 ALUMINUM <br />A U <br />6C ETE <br />A <br />U <br />7 STEELCLAD W/FRP A U <br />B 100% METHANOL COMPATIBLE FRP <br />A U <br />9 GALVANIZED STEEL A <br />5 UNKNOWN <br />A <br />U <br />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 I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P�f, iGTA MONITOR P S 5 GROUNDWATER MONITORING WELLS <br />P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UN (NO P 8 99 OTHER <br />VI- INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br />1. ESTIMATED DATE LAST USED (M07YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH <br />SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑ YES ❑ NO <br />THIS F( <br />-OCAL <br />RM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND C( <br />APPLICANT'S NAME (PRINTED S SIGNATURE) DATE <br />Y <br />YHtG 1. <br />O <br />L" <br />N <br />A <br />N <br />GJi <br />COUNTY# <br />JURISDICTION # <br />AGENCY # FACILITY ID # <br />TANK ID # <br />ail <br />O <br />CURRENT LOCAL AGENCY FACILITY iD p <br />APPROVED BY NAME <br />PHONE # WITH AREA CODE <br />PER MIT NUMBER - PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ■ <br />CHECK# PERMIT AMOUNT SURCHARGE AMT. I FEE CODE I RECEIPT# BY:/'�„ <br />()./' FORM B (6-2966) THIS FORM MUST BE <br />A FACILITY/SITE APPLICATION <br />'A'. UNL.___. CURRENT FORMA' HAS BEEN FILED <br />DATA PROCESSING COPY <br />