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b B r► i r ur C.ALlrUklWIA WATER RESOURCES CONTROL BOARD <br /> FORM `B': UNDERGROUND STORAGE TANK PROGRAM °. <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 5 CHANGE OF INFORMATION 4 0 <br /> ONE ITEM D 7 PERMANENTLY CLOSED T K <br /> 2 INTERIM PERMIT D 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED 0 <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: 78SS W <br /> I'Y/LO Vl-r 14 FARM TANK-YES NO CA) <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY gs'33 Q <br /> A. OWNERS TANK IDN B. MANUFACTURED BY: <br /> C. YEAR INSTALL ED CID <br /> D. TANK CAPACITY IN GALLONS: Q <br /> 060 <br /> 11. TANK NTENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(A./),IS NOT MARKED,C MPLETE ITEM D. <br /> LHAZARDOUS <br /> 1 MOTOR VEHICLE FUEL Lj 2 PETROLEUM B. C. 1 UNLEADED 2 LEADED E0 3 DIESEL <br /> 3 CHEMICALPROpUCT 1 OIL 1PRODUCT 4 GASAHOL 0 5 JET FUEL 0 6 AVIATION GAS <br /> 5 HAZARDOUS 80 EMPTY E395 UNKNOWN 2 WAANOL 0 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> NOT MOTOR VEHICLE FUEL,ENTER NAME OF SUBSTANCE STORED 8 C.A.S.N <br /> C.A.S.N; <br /> Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D <br /> F&TANK <br /> ❑ I DOUBLE WALLED 03 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> D 2;STEEL/IR0N <br /> LLED D 4 SECONDARY CONTAINMENT <br /> 99 OTHER <br /> D I ❑2 STAINLESS STEEL D 3 FIBERGLASS /STEEL CUD W/FIBERGLASS REINFORCED PLASTIC <br /> ❑5 6 POLYVINYLCHLORIDE 0 7 ALUMINUM 0 8 I00%METHANOL COMPATIBLE FRP <br /> E39 10 GALVANIZED STEEL [95 UNKNOWN 99 OTHER <br /> C.INTERIOR L-j I RIBBED UNED ❑2 ALKYD LINING <br /> 3 EPDXY LINING q PHENOLIC LINING <br /> LINING ❑5 GLASRUNNG 6 UNLINED D 95 UNKNOWN <br /> ISUNINGMATERIALOOMPATIBLEWITHIM%METHANOL? YES 0Np D99 OTHER <br /> D. CORROSION ❑1 POLYETHENE WRAP 2 TAR OR ASPHALT 3 VINYL WRAP /FIBBiGL REINFORCED LAS IC <br /> PROTECTION D 5 CATHODICPNDTECTION ❑91 NONE 95 UNKNOWN ❑ <br /> 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE <br /> A U 3 GRAVITY A U 91 NONE A U 95 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 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 A U 91 NONE <br /> C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP <br /> A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZEDSTEEL A U 95 UNKNOWN <br /> 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 /> P 8 1 VISUAL CHECK P 6 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE P E 99 OTHER <br /> I. ESTIMATED DATE LAST USED(MO/YR) <br /> 2. ESTIMATED QUANTITY OF <br /> SUBSTANCE REMAINING IN 3.WAS TANK FILLED WITH <br /> GALLONS INERT MATERIAL? YES 0 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 8 SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> CO� JURISDICTION Y <br /> AGENCY* <br /> FACILITY ID M TANK ID M <br /> MD y 0 U TA d z <br /> CURRENT LOCAL AGlNCT FACILITY ID Y <br /> APPROVED BY IUYE PHONE I WITH AREA CODE <br /> PERMIT NUMBER <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE @ <br /> CHECK Y PERMIT AMOUNT <br /> SURCHARGE AMT. FEE CODE RECEIPTI <br /> FORM a(s-zeas) THIS FORM MUST BE ACCOMPANIED SYFACILI7Y/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />