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%b 1 A It 01' CALIFORNIA 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. _ z <br /> MARK ONLY ❑ 1 NEWPERMIT 3 RENEWALPERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOS,y NK 10 <br /> ONE ITEM 2 INTERIM PERMIT q AMENDEDPERMIT 6 TEMPORARYTANKCLOSURE ❑6 TANKREMOVE6 S <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES M NO W <br /> W <br /> I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK ID It B. MANUFACTURED BY: � <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: <br /> II. TANK NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. 7 MOTOR VEHICLE FUEL 2 PETROLEUMC. ❑ 1 UNLEADED E] 2 LEADED Eij3 DIESEL <br /> 3 CHEMICAL PRODUCT 4 OIL <br /> 6-1 PRODUCT D 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS Ej 60 EMPTY E]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&C.A.S.p <br /> C.A.S.IT <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A.8,C.&D <br /> [JAL YPE OF ❑ I DOUBLE WAILED 3 SINGLE WALLED WITH EXTERIOR UNER 95 UNKNOWN <br /> YSTEM �2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> ANK ❑ 1 STEEL/IRON 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> ATERIAL ❑ 5 CONCRETE 6 POLYVINYLCHLORIDE 7 ALUMINUM E]B IW%METHANOL COMPATIBLE FRP <br /> 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER <br /> C. INTERIOR IRUBBER LINED E] 2ALKYD LINING 3EPDXY LINING 4 PHENOLIC LINING <br /> LINING ❑ 5 GLASS LINING 11 6 UNLINED %UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES [] NO 99 OTHER <br /> D. CORROSION ❑ I POLYETHLFNEWRAP []2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION E]91 NONE 95 UNKNOWN ED99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A U I 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 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C. MATERIAL A U S ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP <br /> A U B 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL 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 S 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN <br /> P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED GATE LAST USED IMO/Yfl) 2. ESTIMATED QUANTITY OF <br /> SUBSTANCE REMAINING IN 3. WAS TANK FILLED WITH <br /> GALLONS INERT MATERIAL? DYES ONO] <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&SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY ID Y <br /> 3 TANK ID N <br /> / 0 / 2 0 6 p <br /> CURRENT LOCAL AGENCY FACILITY TO N APPROVED BY NAME <br /> PHONE N WITH AREA CODE <br /> PERMIT NUMBER /7 rYij PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK/ PERMIT AMOUNT SURCHARGE AMT. FEE CODE '�� <br /> - RECEIPT gy, �S <br /> FORM B(6-29-66) THIS FORM MUST BE ACCOMPANIEL A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />