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STATE OF CALIFORN+ WATER RESOURCES CONTROOARD <br /> FORM 'B': UNDERGROUND STORAGE TANK PROGRAM <br /> LETE ' <br /> Z <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPA SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> 10 <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVED Q9 w <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: as Lc)C GT CJC "F FARM TANK-YES❑ NO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFYOo <br /> A. OWNERS TANK IDA B. MANUFACTURED BY: u ki- _ IV <br /> C. YEAR INSTALLED u & .� 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. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. � C. 1 UNLEADED ❑ 2 LEADED E] 3 DIESEL <br /> F-13 CHEMICAL PRODUCT El4 OIL L ' PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS <br /> ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 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.N C.A.S.N: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXA,B,C,&D <br /> A.TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN <br /> SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER <br /> 1 STEEL/IRON 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 6100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> ❑9 BRONZE ❑ 10 GALVANIZED STEELNKNOWN ❑ 99 OTHER <br /> C. INTERIOR 1 RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY LINING 4 PHENOLIC UNING <br /> LINING ❑ 5 GLASS LINING ❑6 UNLINED 95 UNKNOWN <br /> ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NOOTHER <br /> D.CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TARORASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑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 U 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(a_Fji UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUM A,,AACONCRErE A U 7 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL (3-AUNKNOWN 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 Si VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> i. ESTIMATED DATE LAST USED(MO/YR 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION R AGENCY N FACILITY ID R TANK ID 8 <br /> a c 3 as a l <br /> CURRENT LOCAL AGENCY FACILITY ID P APPROVED BY NAME PHONE M WITH AREA CODE <br /> Loo I �S � CCS I — E—'�s 07 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DAtE <br /> CHECKM PERMIT AMOUNT SUR CHARGE AMT. FEE CODE R CEIPTM BY: <br /> \VW 1 FORM a(6-29-SS) THIS FORM MUST BE ACCOMPANIEDIMA FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> "V V DATA PROCESSING COPY <br />