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STATE OF CALIFORNdi WATER RESOURCES CONTR OARD <br /> FORM `B': UND GROUND STORAGE TANK PRARAM <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING ORMATION FOR EACH TANK. <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION oar. <br /> ONE ITEM 00 <br /> 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVEDCLOI TANK <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: S ❑ I l l <br /> FARM TANK-YES NO 0 W <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY CJ <br /> O) <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: W <br /> O YEAR INSTALLED _ W <br /> D. TANK CAPACITY IN GALLONS: <br /> II. TANK CqNTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL F-12 PETROLEUMg <br /> C. [:] 7 UNLEADED � 2 LEADED IESEL <br /> 0 3 CHEMICAL PRODUCT 0 4 OIL 1 PRODUCT 0 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS ❑ 80 EMPTY 0 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 8 C.A.S.a <br /> C.A.S.a. <br /> Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF D 1 DOI�,BLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER L 95 UNKNOWN <br /> SYSTEM IL— INGLE WALLED D 4 SECONDARY CONTAINMENT <br /> 99 OTHER <br /> B.TANK EELPRON 2 STAINLESS STEEL 3 FIBERGLASS � 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL ❑5 CONCREFE fi POLYVINYL CHLORIDE 7 ALUMINUM ED 8 100%METHANOL COMPATIBLE FRP <br /> E 9 BRONZE 10 GALVANIZED STEEL D 95 UNKNOWN D 99 OTHER <br /> 1 RUBBER LINED 2ALKY0 ING <br /> C. INTERIOR D 3 EPDXY LINING 4 PHENOLIC LINING <br /> LINING ❑ 5 GLASS LINING NLINED 95 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? D YES D NO ❑ 99 OTHER <br /> D. CORROSION ❑ I POLYETHLENEWRAP [:] 2 TAR...SPHALT 03 ANY LW 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 0 91 NONE <br /> #KNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY <br /> B. CONSTRUCTION AU 99 OTHER <br /> U SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C. MATERIAL At U U 5 ALUMINUM A U 6 CONCRETE <br /> A U STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> ] <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER <br /> ---------------- <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P S I VISUALCHECK P 3 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS PS 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING 3 91 NONE P S 95 UNKNOWN P 3 99 OTHER <br /> V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF <br /> SUBSTANCE REMAINING IN 9_WAS TANK FILLED WITH <br /> GALLONS INERT MATERIAL? YES D 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 8 SIGNATURE) <br /> GATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# <br /> FACILITY ID# TANK ID# <br /> CURRENTL AGENCYFACIUTYIDN �/ <br /> APPROVED BY NAME ' PHONE N WITH AREA CODE <br /> PERMIT 0 <br /> PERMIT APPpOVAI DATE PERMIT E%PIRATION DATE <br /> CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE <br /> RECEIPT# BY: <br /> FORM B(6-29-65) THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM `A',UNLESS A15REW FORMA HAS BEEN FILED <br /> DATA PROCFSa1Nc rnev <br />