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STATE OF CALIFORNLA WATER RESOURCES CONTROI BOARD <br /> FORM 'B': UNDE7RGROUND STORAGE TANK PROwAAM ;9� <br /> TANK TANK PERMIT APPLICATION INFORMATION � -°_�, <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 10 <br /> - +1 <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED 12— ca <br /> Q S d/� A{/ FARM TANK-YES NO W <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: 'l w <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY O <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: A <br /> C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: {/ <br /> II. TANK ONTENTS 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 B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 IESEL <br /> 3 CHEMICAL PRODUCT 4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS 80 EMPTY ❑95 UNKNOWN 2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED A C.A.S.# /OO o C.A.S.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D <br /> A TYPE OF ❑ 1 POUBLE WALLED ❑ 3 SINGLE WALLED WITH B(TERIOR LINER ❑ 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT 99 OTHER <br /> ❑ 1 BTEEUIRON ❑2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD WYRBERGLASS REINFORCED PLASTIC <br /> B.TANK F-1 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 UMINUM F-1 610096 METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> 9 BRONZE 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER <br /> ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY UNING OLICUNING <br /> C.INTERIOR ❑ <br /> LINING 5 GLASSUNING F-16 UNLINED 95 UNKNOWN <br /> ❑ ISUNING MATERIAL COMPATIBLE WITH 10096 METHANOL? YES ❑ NO ❑ 99 OTHER <br /> D. CORROSION ❑ 1 POLYETHLEME WRAP ❑2 TARONASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ff� UNKNOWN 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 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 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE IPVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C.MATERIAL A U 5 ALUMINUM A6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZEDSTEEL A U 5 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 /> 'l>/ P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> v 8 6 PRECISION TESTING S 7 PRESSURETESTING P 8 91 NONE P 8 95 UNKNOWN P 8 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 INGALLONS INERT MATERIAL? ❑YES E] 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 B SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> CURRENT LOCAL AGENCY FACILITYUp# � l AP�VEAME PHONE#WITH AREA CODE <br /> J�(/ <br /> PERMIT NUMBER PERMIT APPyRO�VAL PERMIT EXPIRATION DATE <br /> CHECK# PERMIT AMOUNT CHARGE AMT. FEE CODE Ll PTO BY: <br /> FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A ``ENT FORMA' NAS BEEN FILED <br /> DATA PROCESSING COPY <br />