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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM B': UNDERGROUND STORAGE TANK PROGRAM <br /> TANK PERMIT APPLICATION INFORMATION <br /> TANK 40 <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING!,NFORMATION FOR EACH TANK. <br /> 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> [FA;CILITY/SlTE;NA;ME <br /> ONL ❑ 1 NEW PERMIT <br /> ONETEM � 2 INTERIM PERMIT � 4 AMENDED PERMIT <br /> 6 TEMPORARY TANK CLOSURE B TANK REMOVED <br /> FARM TANK NO Z <br /> WHERE TANK IS INSTALLED: ,1 m <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPE IFY <br /> A. OWNERS TANK IDK �VD,N Ei B. MANUFACTURED BY: O/L-. <br /> D. TANK CAPACITY IN GALLONS <br /> C. YEAR INSTALLED 1J W <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. N <br /> A. 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. ❑ 1 UNLEADED � 2 LEADED ❑ 3 DIESEL O'o <br /> 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑ 4 GASAHOL 5 JET FUEL fi AVIATION GAS <br /> ❑ 5 HAZARDOUS <br /> 80 EMPTY 5 UNKNOWN 2 WASTE 7 METHANOL E]99 OTHER(DESCRIBE IN ITEM D.BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF CAS.W <br /> HAZARDOUS SUBSTANCE STORED&C A.S.K <br /> All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,S D <br /> A TYPE OF ❑ 1 DOUBLE WALLED � 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM [a'�NGLE WALLED �4 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEEL/IRON 2 STAINLESSSTEEL 3 FIBERGLASS 4 STEEL CIADWIFIBERGLASS REINFORCED PLASTIC <br /> B.TANK 5 CONCRETE 6 POLYVINYLCHLORIDE �7 ALUMINUM �810096 METHANOL COMPATIBLE FRP <br /> MATERIAL ❑9 BRONZE 10 GALVANIZED STFEL 95 UNKNOWN 99 OTHER <br /> 1 RUBBER UNED 2 ALOO LINING 3 EPDXY LINING /PHENOLIC LINING <br /> C. INTERIOR 5 GUSSLINING LINED F-1 95 UNKNOWN <br /> LINING <br /> IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? YES F-1 NO F-] 99 OTHER <br /> 0.CORROSION ❑ I POLYETHLENEWRAP 0 2 TAR OR ASPHALT F-�3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION NE ❑ 95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMA ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEMTYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B.CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> A 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE <br /> C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 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 /> P 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S S 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 /> I. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK EILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL' <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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY K JURISDICTION K AGENCY K FACILITY ID N TANK ID K <br /> CURRENT LOCALLAAGENCY/AQRyTY ID K APPR VIED BY NA. /! r/ PHONE 0 WITH AREA CODE <br /> OVOV ✓ <3y ` Y <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK# PERMIT AMOUNT /- SURCHARf.E AMT. FEE CODE -. RECEIPTK BY: <br /> FORM B(3-7-88) THIS FORM MUST BE ACCOMPA m._i A FACILITY/SITE APPLICATION, FORM 'A',UNLESS r4RENT FORMA' HAS BEEN FILED <br /> DATA PROCEi Sqi NO G,)PY <br />