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STATE OF CALIFORN WATER RESOURCES CONTIG BOARD <br /> FORM `B': UNDERGROUND STORAGE TANK PROGRAM ' <br /> TANK PERMIT APPLICATION INFORMATION <br /> TANK CO LETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY 1 NEW PERMIT NEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM F] 2 INTERIM PERMIT AMENDED PERMIT 6 TEMPORARY TANK CLOSURE B TANK REMOVED ffn <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: 4-70-7 fi FARM TANK-YES EJ NO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: <br /> G- YEAR INSTALLED D. TANK CAPACITY IN GALLONS: <br /> C.s9 <br /> II. TANK 2ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL F-] 2 PETROLEUM B. C. kZ'l UNLEADED D 2 LEADED 3 DIESEL <br /> F__] 3 CHEMICAL PRODUCT F-] 4 OIL PRODUCT ❑ 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> El 5 HAZARDOUS 0 BD EMPTY ❑ 95 UNKNOWN E:] 2 WASTE 1:1 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.#: <br /> x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.&D <br /> A.TYPE OF 1 DOUBLE WALLED F-1 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM ❑ 2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> ❑ 1 STEEL/IRON 2 STAINLESS STEEL F-] 3 FIBERGLASS EZ"4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK g CONCRETE 6 POLYVINYL CHLORIDE F-] 7 ALUMINUM 8 100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> 9 BRONZE 10 GALVANIZED STEEL 0 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED ALKYD LINING El 3 EPDXY LINING 4 PHENOLIC LINING <br /> LINING <br /> C. INTERIOR F-15 GLASS LINING V6 NLINED 95 UNKNOWN <br /> 0 ISLINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑ NO E:] 99 OTHER <br /> D,CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TAR OR ASPHALT 3VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION E] 5 CATHODIC PROTECTION 0 91 NONE El 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�p PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALLED A DOUBLE WALLED A U 3 LINED TRENCH 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) <_u FIBERGLASS PIPE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 10044 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 /> J5 1 VISUAL CHECK ,2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS(P ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> Im <br /> �lkJ S B PRECISION TESTIN 7 PRESSURE TESTING P S 91 NONE S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MO/YH) 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 PERRJUR/Y,AND TO THE BEST OF MY KNOWLEDGE,)S TRUE AND CORRECT. <br /> APPL T'S NAME)PRINTED&SIGNATURE)) �/,/ I�G /rT� DATE <br /> LOCAL AGENCY USE OI LY h L <br /> COUNTY# JURISDICTION# AGENCY# } FACILITY ID# TANK ID# <br /> .� +r I I 11] EI I I I 0 <br /> 1- <br /> CURRENTLOCAL AGENCY FACILITY ID# APPR D BY NAME PHONE#WITH AREA CODE <br /> �h <br /> PERMIT NUMBER PERMIT APPROVAL AT RMIT E IRATI DATE <br /> CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE 4RECEIPT# BY: <br /> FORMB(3a-s8) THISFORM MUST BE ACCOMPANIESdYA FACILITYISITE APPLICATION, FORM `A',UNLESSuRRENT FORMA' NAS BEEN FILED �� <br /> DATA PROCESSING COPY <br />