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STATE OF CALIFORNL-. WATER RESOURCES CONTRA_ BOARD <br /> FORM 'B': UNDERGROUND STORAGE TANK PROGRAM <br /> TANKTANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z <br /> 10 <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPO)RARYTANK CLOSURE FLJ<TANK REMOVED Q 9 <br /> a W <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: ARM TANK-YE8❑ NO (,) <br /> 0) <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY CA) <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: <br /> C YEAR INSTALLED D. TANK CAPACITY IN GALLONS: D <br /> II. TANK C TENTS 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 ZIPRODUCT <br /> C. ❑ 1 UNLEADED LEADED ❑3 DIESEL <br /> F-13 CHEMICALPRODUCT ❑ 4 OIL ❑4 GASAHOL ❑ 5 JET FUEL E]6 AVIATION GAS <br /> ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN REM D,BELOW) <br /> D. IF NOT MOTOR VEHI E FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTA E STORED S C.A.S.# C.A.S.W <br /> 111. TANK CONSTRUC ON MARK ONE ITEM ONLY IN BOXA,B,C,BD <br /> A.TYPE OF ❑ 1 DOUBLE LLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN <br /> SYSTEM ❑2 SINGLE D ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER <br /> ❑ 1 STEBUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS F-14 STEEL CLAD WIRBERGLSS REINFORCED PLASTIC <br /> B. TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM 718188%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ UNKNOWN ❑99 OTHER <br /> ❑ 1 RUBBER LINED 2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC UNING <br /> C. INTERIOR <br /> LINING ❑5 GLASS LINING 6 UNLINED ❑95 UNKNOWN <br /> ❑ IS LINING MATERIAL COMPATIBLE H18D%METHANOL? ❑YES ❑ NO ❑ 99 OTHER <br /> D. CORROSION ❑ I POLYETHLENEWRAP ❑ TAR OR ASPHALT F-13 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION [:]91 ONE ❑95 UNKNOWN ❑99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF AB EGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U XPRESSURE 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 AJOUBLEWALUED 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 S INLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUM A U 5 CO RETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 UN OWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMA ,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 6 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURETESTING P 8 1 NONE P S 95 UNKNOWN P 8 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLO D IN PLACE <br /> 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OU TITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REM NING IN GALLONS INERT MATERIAL? ❑YES ❑ NO li <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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> Od b � 7 U0 © <br /> CURRENT LOCAL AGENCY FACILITY ID X APPROVED BY NAME`l 9� PHONE#WITH AREA CODE <br /> I �_ I ,. <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECKM PERMIT AMOUNT SURCHARGE AMT. FEE CODEI -ECE1PT# BY: <br /> FORM B(6-29-Re) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RRENT FORMA' HAS BEEN ALED <br /> DATA PROCESSING COPY _ <br />