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STATE OF CALIFORn..A WATER RESOURCES CON',,_,JL BOARD <br /> FORM 'B': / UNDERGROUND STORAGE TANK PROGRAM <br /> TANK ( � � / TANK PERMIT APPLICATION INFORMATION <br /> LC MPLETE A SEPANAi E FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> I---I 10 <br /> MARK ONLY ❑ I NEIN PERMIT u 3 RENEWAL PERMIT [-] 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSgl-lANK <br /> ONEITEMI F-12 INTERIM PEEM.IIt I AMENDED PERMIT Ej 6 TEMPORARY TANK CLOSURE �8 TANK REMOVED // <br /> FARM TANK-YES O U <br /> FACILftYAlf!NAY!WHERE LANK N INSTALLED: <br /> A. <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY F► <br /> A. OWNERS TANK 101 B. MANUFACTURED BY: <br /> C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: <br /> II. TANK CONTENTS IF(A.f),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. of MOtd1VEFMCLEFl1EL [:1 2 FETRmEUL1 I B� �� C. ❑ 1 UNLEADED OED L] 3 DIESEL <br /> 3 CHEmm PRODUCT E] A DK 1 3_ PRODUCT 0 /GASAHOL 0 5 JET FUEL fl] 8 AVIATION GAS <br /> 5 HAZARDOUS /0 EMPTY [::]95 UNKNOWN Ej 2 WASTE 0 7 METHANOL 0 99 OTHER(DESCRIBE IN ITEM D.BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED S CA.S.I CA.S.8: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,•D <br /> A TYPE OF ❑ 1 DCUM111 AUE1 03 SINGE WALLED WITH ENTERON LINER UNItNOYN <br /> SYSTEM E]2 SMf.E WAUM 04 SECONDARY CONTAINMENT 99 OTHER — <br /> 0 1 SIEEUmm Ej 2 STAINLESSSTEE E]3 FREKRASS O N STEEL CUD WIRRERGLASS RENPORCED PLASTIC <br /> S.TANK E]5 CONCRETE O f Partum CHLORIDE EJIAUovoum0 8 18011 METHAHa COMPATBLE FRP <br /> MATERIAL <br /> f KONtE 0 10 GALVANIZED STEEL UNKNOWN El 99 OTHER <br /> MIER L] I RUBBER Loa 0 2 ALKYD UNNO O 3 EPDXY UMW 0 1 PHMICUMNG <br /> C UNINIROO M s oLA96LIBNo ❑I VEINED D- 95 UNKNOWN <br /> 0 18UNINO NATURAL CO PAtIKE WITH IW%METHgn? ❑YES E]NO 0 99 OTHER <br /> D.COM I*ON ❑1 POLYETMEE WRAP O 2 TAR OR ASPHALT 0 3 VNR.WRAP E]/FIBERGLASS REINFORCED PLASTIC <br /> PIIOtECTION ❑5 CADIODIC PBO1ECll0N Ej91 NDNE 0-9 I5 m m EJ99 OTHER <br /> IV. PIPING INFONMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYLE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A tC 95 UNKNOWN U 99 OTHER <br /> S.COIMTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A5 UNKNOWN U 99 OI HER <br /> A U I STEEL/1104 A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U I FIBEROLASS PIPE A U 91 NONE <br /> C.MATERIAL A U 6 ALUMINUM A U 6 CONCSEIE_ A U 7 STEEL CLAD W/FRP A U 6 IRR%METHANOL COMPATBLE FRP <br /> A U I GALVANIZED STEEL A NC 96 UNKNOW A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE p FOR PRIMARY,OR B FOR SECONDATIY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> B I VBUALcwcK P I 1 INVENTORY RECONCILIATION 0 1 3 VADOSE WELLS P B I ELECNMNI�MONITOR ► B 5 GROUND WATER MONITORING WFLLS <br /> P S B PRECISION TESTIND P I 7 PRESSURE TESTING P S 91 NONE P 0 95 UNKNOWN i ► B 99 OIHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> L ESTIMATED DATE UST USED(MOYYR) 2.ESTIMATED QUANTITY OF 3,WAS TANK FILLED WITH <br /> SUBSTANCE IIEMAININ0 N GALLONS INERT MATERIAL? DYES []NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND COnnEC F. <br /> APPUCAM'8 NAME(PRINTED S SIGNATURE) DATE <br /> LOCAL AGENCY US ONLY <br /> COUNTY/ JURISDICTION I AGENCY$ FACILITY ID/ TANK ID/ <br /> CURRENT LOCAL AGENCY FACILITY 101 APPROVED BY NAME PHONE 0 WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CNlCR I PERMR AMOUNTBURCNARGE AMT. FEE COD! RECEIPT 1 eY: _. <br /> A <br /> Fonts 8M 2F 86) TWI FOAL(SIM IE ACCOMPANIED ET A FAC&MAITE APPUCATWN, FO R M 'A',UNLESS A CURRENT FORM'A' HAS SEEN FILED <br /> nA*& nnnnEORIMn hnnv <br />