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STATE OF CALIFORNI WATER RESOURCES CONTR(.30ARD <br /> FORM.'B'• , UNDERGROUND STORAGE TANK PROGRAM <br /> ;•TANK. .• ,. .,• TANK PERMIT APPLICATION INFORMATION <br /> ... COMPLETE A SEPARATE FORD WITH THE FOLLOWING INFORMATION FOR EACH TANK. ZP <br /> ` <br /> MARK•ONLY i -❑ 1 NEW PEAMTT Q RM <br /> 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION Q T PERMANENTLY CLOSED• 10 <br /> ONE ITEM ( Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q 6 TEMPORARY TANK CLOSURE Q A TANK REMOVED %`✓I <br /> FACILITY/SITE NAME WHERE TANK 18 INSTALLED: G//Q. 5-7k V y5-Zo 6FARM TANK-YES `ti NO TV <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY O <br /> CQ <br /> A OWNERS TANK ID 1 B. MANUFACTURED BY: <br /> C.YEAR INSTALLED k D. TANK CAPACITY IN GALLONS: <br /> Ii. TANK CONTENTS IF(A.1),19 MARKED,COMPLETE ITEM C.IF(A.1).IS NOT MARKED,COMPLETE ITEM D. <br /> A Q 1 MOTOR VEHICLE FUEL Q 2 PETROLEUM B. C. ❑ 1 UNLEADED2 LEADED <br /> Q 7 DIESEL <br /> Q S CHEMICAL PRODUCT ❑ 4 OIL ❑ T PRODUCT Q 4 GASAHOL Q S JET FUEL ❑6 AVIATION GAS <br /> Q 5 HAZARDOUS Q 60 EMPTY ❑95 UNKNOWN Q 2 WASTE Q 7 METHANOL Q 99 OTHER(DESCRIBE IN REM D.BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED 8 CAS.1. CAS.E: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOKA.B,C,AD <br /> . . A.TYPE OF• ❑I DOUBLE WALLED Q 7 SINGLE WALLED WITH DITFHIOR LINER Q 95 wmwN <br /> SYSTEM Q 2 SINGLE WALLED Q I SECONDARYCONTAWMENT ❑99 OTHER <br /> Q 1 STEELNION ❑2STAINLESS STEEL - ❑ 7FIOMASS ❑I STEEL GAD W/FWIGASS REWFORCED PUSTC <br /> B.TANK ❑5 O)NCFFIE Q E POL"IMOILORDE Q T AWYINUM Q t IM11,USHANOLCOMPARBIEFIIP <br /> MATERIAL,;:. <br /> -:;: ❑9 BRONZE Q 10 GALVANIZED STEEL ❑ 95 LN.NM ❑99 OTHER <br /> C.INTERIOR I MJBBFAUNED . .. Q 2 AU(Y,DLNWD ❑ 7 EPWUNINO ❑I PHENOIICUNING <br /> LINING,, '❑ '+,GLASS UNNO Q 6 UNLINED Q 95 Uw(Nm <br /> Q IS LINING MATERIALCOMPATISLEWRH100%METHANOL? ❑YES Q NO Q 99 OTHER <br /> D.CORROSION ❑ I.POLYETILEWWMP Q 2 TMIORASRYLT Q 3 V971LWRAP Q 4 RBEAGLASSREWFIXEDRASTIC <br /> PROTECTION.. Q S GTHODIC RIOTECIION Q 91 NONE ❑ 95 UNKNOWN Q 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 9 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 POLYVINYLCHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE <br /> C.MATERIAL 'A U 5 ALUMINUM A U B CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZEDSTEEL A U 96 UNKNOWN A U "OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P t 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 1 3 VADOSE WELLS P t I ELECTRONIC MONITOR P 1 5 GROUND WATER MONITORING WELLS <br /> P t 1 PRECISION TESTING P t T PRESSURE TESTING P t 91 NONE ► t 95 UNKNOWN P t 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 IN WERE MATERIAL? DYES Q NO <br /> GALLONS <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE,)S TRUE AND CORRECT. <br /> APPLICANTS NAME(POINTED A SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY/ . ' .JURISDICTION/ AGENCY/ FACILITY ID Y TANK ID/ <br /> CURRENT LOCAL AGEN4C <br /> •Y <br /> /fACILITY 10 1 APPROVED BY NAME PHONE/WITH AREA CODE <br /> iVb' . C <br /> PLRMITXUMBER J PERMIT APPROVAL DATE PERMIT EXPIRATION OAT[ <br /> OHEDKI PERMIT AMOUNT BVRCHANOE AMT. REE CODE 0--3- <br /> ECEIPTI <br /> �•., FORM a(6.29•50) THIS FORM MUST BEACCOMPANIED BYAFACILITYISITE ATPUCATION. FORM 'A' IINI_FSC 4 PIINRFNT F/IBU'1• MlC PF4.,[q 11 <br />