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STATE OF CALIFORNI& WATER RESOURCES CONTRO OARD <br /> FORM `B': UAN GRO T APPLIICATIONAGE ANK I FORMATION &® o <br /> TANK AM <br /> TANK PERMIT <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFO ION FOR EACH TANK. <br /> MARK ONLY ❑ I NEW PERMIT �3 RENEWAL PERMIT J�jfCHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM 2 INTERIM PERMIT F-1 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE B TANK REMOVED J )- N <br /> r7 Oy, K S�_ FARM TANK-YES NO -ch.NAME WHERE TANK IS INSTALLED: oC Q(J / `Jl <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> :JI <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: <br /> C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: <br /> 11. TANK CONTENTS IF(A.1),IS MARKED COMPkETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. F_� 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. ❑ 1 UNLEADED E] 2 LEADED 3 DIESEL <br /> 3 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 C.A.S.#'. <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX'A,B,C,&D <br /> ❑ I DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> A.TYPE OF <br /> SYSTEM 2 SINGLE WALLED F-14 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEBUIRON 2 STAINLESS STEEL F-1 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK 5 CONCRETE 6 POLYVINYLCHLORIDE El 7 ALUMINUM 8 100%METHANOL COMPATIBLE FRP <br /> MATERIAL ❑9 BRONZE F-1 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED F-1 2 ALKYD LINING 3 EPDXY LINING F_�4 PHENOLIC LINING <br /> C. INTERIOR5 GLASSUNING � 6 UNLINED 95 UNKNOWN <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? E]YES 0 NO 99 OTHER <br /> D.CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TARORASPHALT F� 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION 0 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 U 95 UNKNOWN A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOURLE WALLED A U 3 LINEDTREN , A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLOR/DE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE <br /> C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%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 1 VISUALCHECK P 5 21NVENTORYRECONCILIATION P S 3VADOSEWELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH <br /> 1. ESTIMATED DATE LAST USED(MO/VR) SUBSTANCE REMAINING IN INERT MATERIAL? VES NO <br /> GALLONS <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> DATE <br /> APRIL CANT'S NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> ECOUNTY# JURISDRISDICTION# AGENCY% <br /> FACILITY ID# TANK ID# <br /> APPROVED BY NAME PHONE#WITH AREA CODE <br /> ILITY ID# / / ,r PERMIT APPROVAL DATE PI XPIRATION E <br /> AMOUNT SURCHARGE AMT. FEE CODE RECEIPTk BY: <br /> r� FORM B(6-29-88) THIS FORM MUST BE ACCOMPAIN A FACILITYISRE APPLICATION, FORM `A',UNLESS A RENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />