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STATE OF CALIFORNO WATER RESOURCES CONTOOARD <br /> FORM 'B': O LAND GROUND STORAGE TANK PR RAM <br /> TANK TANK PERMIT APPLICATION INFORMATION a <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INF ATION FOR EACH TANK. _ z <br /> MARK ONLY ❑ 1 NEWPERMIT 3 RENEWALPERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK to <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: RM TANK-YES 0 NO W <br /> r <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY cr) <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: N' <br /> O YEAR INSTALL D. TANK CAPACITY IN GALLONS: <br /> IL TANK C TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. i MOTOR VEHICLE FUEL F-1 2 PETROLEUM B. C. 1 UNLEADED 2 LEADED 3 DIESEL <br /> 3.CHEMICAL PRODUCT 4 OIL PRODUCT 4 GASAHOL �,5 JET FUEL 8 AVIATION GAS <br /> ❑5 HAZARDOUS 80 EMPTY 0 95 UNKNOWN E] 2 WASTE D 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUEISTANCE STORED&C.A.S.# C.A.S.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF ❑ 1 DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER MllruNKNOWN <br /> SYSTEM ❑ 2 SINGLE WALLED 4 SECONDARY CONTAINMENT [D 99 OTHER <br /> 1 STEEL/IRON 26TAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B'MATERIAL M 5 CONCRETE 6 POLYVINYLCHLORIDE 7 AL B 100%METHANOL OOMPATIBLEFRP <br /> El 9 BRONZE 10 GALVANIZED STEEL Efr95'UNkNOWN ❑ 99 OTHER <br /> C. INTERIOR <br /> 1 RUBBERLINED 2ALKYD LINING 3EPDXY LINING ❑4P CLINING <br /> ' <br /> LINING ❑5 GLASSUNING 6 UNLINED 95 UNKNOWN <br /> E] IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES O NO 99 OTHER <br /> D.CORROSION ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT 3 LWRAP 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 Lt'T5-UNKNOWD A U 99 OTHER <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONEA LANK U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIB A U 91 NONE <br /> C.MATERIAL A U 5 ALUMINUM A U B A U7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL 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 VADO SE WELLS P NIC MONITOR P 8 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE S 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 0 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# mGENCY# FACILITY ID# TANK ID# <br /> CURREN CALAGENCY FACILI6 IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> / PER N PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> / CHECKN PERMIT AMOUNT SURCHARGE AMT. FEE CODE R CEIPTN By; <br /> FORM B(8-29-ee) THIS FORM MUST BE ACCOMPANIED tlY A FACILITY/SITE APPLICATION, FORM `A`,UNLESS A CURRENT FORMA' HAS BEEN FIFILELE D <br /> /// D <br /> DATA PROCESSING COPY <br />