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STATE OF CALIFORN& WATER RESOURCES CONTPO BOARD <br /> FORM `B': UND RGROUND STORAGE TANK PRU RAM Qp <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWIN INFORMATION FOR EACH TANK. z <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 7 PERMANENTLY CLOSEED CHANGE OF INFORMATION D 10 <br /> ONE ITEM TANK <br /> 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: // FARM TANK-YES❑ NO w <br /> I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK ID INQ <br /> B. MANUFACTURED BY: (,V <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: S' 2Otj <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D <br /> A. V, MOTOR VEHICLE FUEL 7 2 PETROLEUM B. :!:C1 UNLEADED ftDED 3 DIESEL <br /> 3 CHEMICAL PRODUCT q OIL �i PRODUCT 4 GASAHOL D 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS 80 EMPTY [-]95 UNKNOWN 2 WASTE 7 METHANOL 0 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.q: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF ❑ I DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEEUIRON 2 STAINLESS STEEL ❑ 3FIBERGLASS 4STEEL CIAO W/FIBERGLASS REINFORCED PLASTIC <br /> B.MATERIAL 5 CONCRETE 6 POLYVINYLCHLORIDE D 7 ALUMINUM 8100%METHANOL COMPATIBLE FRP <br /> 9 BRONZE E] 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> C.INTERIOR <br /> 1 RUBBFALINED 0 AIKYDUNING 3EPDXY LINING 4 PHENOLIC LINING <br /> LINING ❑5 GLASS LINING 6 UNLINED 95 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑ NO 99 OTHER <br /> D.CORROSION ❑ I POLYETHLENEWRAPTARORASPHALT D 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION � NONE 095 UNKNOWN 0 99 OTHER <br /> IV. PIPING INFORMAT N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A.SYSTEM TYPE A(qd SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B.CONSTRUCTION 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U %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 89/95 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 /> 4-9 <br /> P S I VISUAL CHECK V S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P 9 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? DYES D 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# II AITTGENCYII# FACILITY ID# TANK ID# <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> (, CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# <br /> rI� BY:� <br /> N1v FORM B B-29-88) THIS FORM MUST BE ACCOMPANIE FACILITY/SITE APPLICATION, FORM `A',UNLESS A L. RENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />