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STATE OF CALIFORNIo WATER RESOURCES CONTROI -")ARD 0 <br /> FORM `B': UNDERGROUND STORAGE TANK PROG.SAM <br /> TANK TANK PERMIT APPLICATION INFORMATION ' <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION n7 P MANENTLY CLO K <br /> ONE ITEM El INTERIM PERMIT F-14 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE �(r,88 TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: 11V kl FARM TANK-YES❑vNOI <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY �3 <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: rL <br /> C YEAR INSTALLED I D. TANK CAPACITY IN GALLONS: <br /> II. TANK 22NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. FV1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL <br /> ❑ 3 CHEMICAL PRODUCT F-] 4 OIL Yll"PRODUCT ❑ 4 GASAHOL ❑>5k 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 Ir <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# M i X M F elf-< C.A.S.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPEOF ❑ DOUBLE WALLED F-] 3 SINGLE WALLED WITH EXTERIOR UNER ❑ 95 UNKNOWN <br /> SYSTEM 2 INGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER <br /> 1 STEEL/IRON ❑ 2 STAINLESS STEEL F-] 3 FIBERGLASS F-] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE 7 UMINUM ❑ 8 100%METHANOL COMPATIBLE FAP <br /> MATERIAL <br /> ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 09 95 UNKNOWN ❑99 OTHER <br /> C. INTERIOR <br /> F-11 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING n 4,WENOUC LINING <br /> / <br /> LINING ❑ 5 GLASS LINING ❑ r-�/� <br /> 6 UNLINED 95 UNKNOWN <br /> ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER <br /> D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 INYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 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 A U 3 GRAVITY A U 91 NONE A V,95 UNKNOWN A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALLED A 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE U 95 UNKNOWN A U 99 OTHER <br /> A U 1 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 A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U'95 UNKNOWN A U 99 OTHER <br /> V. L AK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P 'S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. 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# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> CURRENT LOCAL AGENCY FAC LITY ID# / APPROVED BY NAME PHONE#WITH AREA CODE <br /> 81, S/ <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE z <br /> CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# .- <br /> �� J <br /> .V FDRM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A CURRENT FORMA' HAS BEEN FILED \� <br /> DATA PROCESSING COPY <br />