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,Z­717 , _._ 7 <br /> STATE OF CALIFORN WATER RESOURCES CONTR BOARD <br /> FORM 'B'. <br /> UND GROUND STORAGE TANK PR RAM <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. � <br /> MARK ONLY 1 NEW PERMIT 1:13 RENEWAL PERMIT <br /> ONE ITEM 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CL <br /> 2 INTERIM PERMIT 4 AMENDED PERMIT ` K <br /> 6 TEMPORARY TANK CLOSURE 6 TANK REMOVED l r <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: 0�� <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY FARM TANK-YES NO <br /> =ANERS K ID# ? B. MANUFACTURED BY: <br /> LED <br /> D. TANK CAPACITY IN GALLONS: S'/�v <br /> II.nNR <br /> ENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> EHICLE FUEL 2 PETROLEUM <br /> B. Cr 1 UNLEADED LEADED <br /> L PRODUCT 4 OIL Q 3 DIESEL <br /> PRODUCT ❑4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> OUS SD EMPTY 0 95 UNKNOWN <br /> 2 WASTE 7 METHANOL E] 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> VEHICLE FUEL,ENTER NAME OF <br /> BSTANCE STORED&C.A.S.# <br /> C.A.S.#: <br /> x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,,S D <br /> [PROTECTION <br /> E OF �UBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER <br /> TEM 95 UNKNOWN <br /> 2 SINGLE WALLED 4 SECONDARY CONTAINMENT <br /> 99 OTHER <br /> 1 STEEUIRON 2 STAINLESS STEEL 3 FIBERGLASS <br /> K d STEEL CLAD WlFIBERGLASS REINFORCED PLASTIC <br /> ERIAL ❑ 5 CONCRETE El 6 POLYVINYL CHLORIDE Q 7 ALUMINUM 0 g 100%METHANOL COMPATIBLE FRP <br /> ��Elp 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> RIOR E l i RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> G 5 GLASS LINING fi UNLINED <br /> 95 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES E] NO 99 OTHER <br /> OSION Q 1 POLYETHLENE WRAP 2 TAR OR ASPHALT E]3 VINYL WRAP <br /> d FIBERGLASS REINFORCED PLASTIC <br /> 5 GATHOOIO PROTECTiOy F g1 NONE 95 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 <br /> A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION AM 1 SINGLE WALLED A U 2 DOUBLE WALLEQ A U 3 LINED TRENCH A U 95 UNKNOWN <br /> A U 1 STEEL/IRON A U 99 OTHER <br /> A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE <br /> C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 8 100%METHANOL COMPATIBLE FAP <br /> A U 99 OTHER <br /> - i <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P S 1 VISUAL CHECK / Pl S 2 INVENTORY RECONCILIATION P S 3 VADDSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTEINGVP S 7 PRESSURE TESTING P $ 91 NONE P S 95 UNKNOWN <br /> P S 99 OTHER <br /> VL INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1, ESTIMATED DATE LAST USED(MO/YR) <br /> 2. E TI ATED QUANTITY OF <br /> S B T CE REMAINING!N 3. WAS TA LLED WITH <br /> GALLONS INE T L? []YES NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENAL OF PERJURY,AND TO THE BEST OF MY KNOWLED E,!S TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# <br /> FACILITY 1D# TANK ID# <br /> CURRE T LOCAL AGENCY FACILITY ID# <br /> APPA ED Y NAE PHONE#WITH AREA CODE <br /> PERMIT NUMBER <br /> PERMITAPPROVAL E PERMIT EXPIRATION DATE <br /> CHECK# PERMIT AMOUNT SURCHARGE AMT. <br /> FEE CODE RECEIPT k <br /> BY: <br /> FORM R(3-7-e6) THIS FORM MUST BE ACCOMPANI Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />