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STATE OF CALIFORNI. WATER RESOURCES CONTRC;ARD "•°- <br /> FORM 'B': UNDE3ROUND STORAGE TANK PRO AM <br /> TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> TANK Z <br /> 1 NEW PERMIT F-] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED TANK <br /> MARK ONLY <br /> ONE ITEM 2 INTERIM PERMIT F-14 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 6 TANK REMOVED o/ W <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED FARM TANK-YES❑ NO IV <br /> 00 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-%0 SPECIFY W <br /> W <br /> A. OWNERS TANK 10# 07/ B. MANUFACTURED BY: <br /> C. YEAR INSTALLED <br /> D. TANK CAPACITY IN GALLONS: <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL F-1 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT F-1 4 OIL P 1 PRODUCT ❑4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS D 80 EMPTY D 95 UNKNOWN 2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: A <br /> HAZARDOUS SUBSTANCE STORED&I A.S.# <br /> A IA <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,t D <br /> A.TYPE OF F-11 DOUBLE WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 5;T2 SINGLE WALLED F-�4 SECONDARY CONTAINMENT E]99 OTHER I <br /> 1 STEEL/IRON 2 STAINLESS STEEL 3FIBERGLASS 4STEEL CLAD W/RBERGLASS REINFORCED PLASTIC <br /> B.TANK 5 CONCRETE F-�6 POLYVINYLCHLORIDE F-�7 ALUMINUM B 1DD%METHANOL COMPATIBLE FRP <br /> MATERIAL 9 BRONZE r7 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED F-1 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR 5 GLASS LINING UNLINED ❑ KNOWN <br /> LINING <br /> DISUNING MATERIAL COMPATIBLE WITHIOQ%METHANOL? YES � NO 990THFA <br /> D. CORROSION ❑1 POLYETHLENE WRAP 2 TAR OR ASPHALT41NYLWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 91 NONE �UNKNOWN ❑99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABO GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A 1 SUCTION A PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B. CONSTRUCTION U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 9/ 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 FIBERGLASSPIPE A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUM A b 8 CONCRETE A U 7 STEELCLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A 95 UNKNOWN A U 99 OTHER <br /> /V. LEAK DETECTION SYSTEM CIRCLE PFOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1.ESTIMATFD, ,A 7V DATE LAST USED(MO/YR) 2. ESTIMATED QUA N TY OF 3.WAS ANK FILLED WITH <br /> /„1/, SUBSTANCE WNG IN 1MTERIAL? YES C NO <br /> GALLONS /V <br /> THIS FOAM 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) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> U o�� 0 0 6 <br /> CURRENT LOCAL AGENCY F ILITYIDN ApppOVED BY NA PHONE N WITH AREA CODE <br /> v�b a NN��/ `/ zD <br /> PERMIT NUMBER /PERRMMIITTAPPR VALDA 4 PERMIT EXPIRATION DATE <br /> lQ r zo v <br /> CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT' <br /> BY: <br /> FORMS(6-29-88) THIS FORM MUST BE ACCOMPANIE Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESSA'CORRENT FORMA' HASBEENFILED / <br /> DATA PROCESSING COPY _. <br />