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STATE OF CALIFORNII& WATER RESOURCES CONTROJXOARD <br /> FORM 'B'- UNDE GROUND STORAGE TANK PRO AM <br /> (f-' TANK PERMIT APPLICATION INFO MATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING 1 RMATION FOR EACH TANK. Z <br /> TANK o <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT Ej 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> FARM TANK-YES❑ NO CA) <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: Fa <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY —4 <br /> A. OWNERS TANK 10# <br /> B. MANUFACTURED BY: �J;- <br /> C.YEAR INSTALLED LTOL__- D. TANK CAPACITY IN GALLONS: L/ v <br /> II. TANK 9014TENTS IF(A.1).IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. Wrl MOTOR VEHICLE FUEL 2 PETROLEUM B C ❑ 1 UNLEADED 2 LEADED IESEL <br /> 3 CHEMICAL PRODUCT 4 OIL 1 PRODUCT ❑ 4 GASAHOL 5 JET FUEL E] 6 AVIATION GAS <br /> 5 HAZARDOUS BO EMPTY [:]95 UNKNOWN 2 WASTE El 7 METHANOL Ej 99 OTHER(DESCRIBE IN ITEM D,BELOW( <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.W <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D <br /> A.TYPE OF ❑ I AWA ❑3 SINGLE WALLED WITH EXTERIOR UNER 95 UNKNOWN <br /> SYSTEM EVSINWfAUUED F1 4 SECONDARY CONTAINMENT [:j 99 OTHER <br /> 1 STEELIRON F-�2 STAINLESS STEEL F-1 3 FIBERGLASS 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC <br /> B.TANK 5 CONCRETE 7 6 POLYVINYLCHLORIDE F7 7 ALUMINUM a 100%MENANOLCOMPATIBLEFSP <br /> MATERIAL <br /> 9 BRONZE F-1 10 GALVANIZED STEEL 0 95 UNKNOWN 99 OTHER <br /> 1 RUBBERUNED 2 ALKYD LINING E]3 EPDXY LINING 4 PH CLINING <br /> C. INTERIOR F-15 GLASS UNING F—]6 UNLINED 5 UNKNOWN <br /> LINING {' <br /> ISUNING MATERIAL COMPATIBLE WITH 100%M L? �YES 0 NO �M OTHER <br /> D.CORROSION F-11 POLYETHLENEWMP 2 OR ASPHALT 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION F-]5 CATHODIC PROTECTION 91 NONE D 95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A 1 SU 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 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> 1 STEE A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE <br /> C.MATERIAL 5 ALUMINUM A U- 6 CONCRETE A U 7 STEEL CLAD W/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 I VISUALCHECK P S 2 INVENTORY RECONCILIATION P VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING S 91 ON 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? E]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 /> o Q Q <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE k WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> [CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: <br /> C <br /> FORMe(6-29-86) THIS FORM MUST BE ACCOMPAAMYAFACILITYISITEAPPLICATION, FORM `A',UNLESS ACURRENT FORMA' HAS BEEN FILED / <br /> DATA PROCESSING COPY ' <br />