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STATE OF CALIFORNib WATER RESOURCES CONTR OARD <br /> FORM 'B': UNDE GROUND STORAGE TANK PR1RAM <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ _� z <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 �NK REMOVED O <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: 3 FARM TANK-YES❑ NO N <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: v <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: �O 0 <br /> I. TANK CONTENTS 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 B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL <br /> F-13 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 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.# C.A.S.p: <br /> 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF ❑ 1 DOUBLEWALLEO ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN <br /> SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER <br /> ❑ 1 STEELARON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD WIFISERGIASS REINFORCED PLASTIC <br /> B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 IW%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER <br /> C. INTERIOR ❑ 1 RUBBER LINED [:]2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING <br /> LINING ❑ 5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN <br /> ❑ IS LINING MATERIAL COMPATIBLE WITH IDD%METHANOL? ❑YES ❑ NO ❑99 OTHER <br /> D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4LBERILASSREINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑9 <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 U 95 UNKNOWN A U 99 OTHER <br /> B.CONSTRUCTION A 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 /> 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 U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN 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 I 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 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P 8 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 /> 3 � aol7o3 Doo / <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> a � <br /> IPERMIT NUMBER PERMIT APPROVAL DATE ERMIT EXPIRATION DATE <br /> JCHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: <br /> FORM B(6-29-68) THIS FORM MUST BE ACCOMPANIED011 A FACILITY/SITE APPLICATION, FORM 'A',UNLESS At <br /> WRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />