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STATE OF CALIFORNI0 WATER RESOURCES CONTRO�ARD <br /> FORM `B': UNDERGROUND STORAGE TANK PROGRAMGo <br /> TANK li TANK PERMIT APPLICATION INFORMATIONCOMPLETE A SEPARATE FORM WITH THE FOLLOWING FORMATION FOR EACH TANK. z <br /> MARK ONLY 1 NEW PERMIT 3 RENEWALPERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLO K 10 <br /> ONE ITEM tA 2 INTERIM PERMIT 4 AMENDED PERMIT 0 6 TEMPORARY TANK CLOSURE 0 8 TANK REMOVED V <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: Z w <br /> FARM TANK-YES 0 NO W <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY � <br /> A. OWNERS TANK ID# �/• ;(Alu), <br /> UFACTURED BY: IV <br /> C. YEAR INSTALLED Ila Q K CAPACITY IN GALLONS: <br /> II. TANK ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM OT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL 2 PETROLEUM C. ❑ 1 UNLEADED 0 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT q OIL ❑4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS ED 80 EMPTY 95 UNKNOWN ❑ 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.# <br /> C.A.S.#: <br /> III. TANK CONSTRU TION MARK ONE ITEM ONLY IN BOX A,B,C,A D <br /> A.TYPE OF DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER D 95 UNKNOWN <br /> SYSTEM SINGLEWALLED 4 SECONDARY CONTAINMENT 0 99 OTHER <br /> B.TANK 1 STEEL/IRON 2 STAINLESS STEEL 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL ❑5 CONCRETE 6 POLYVINYLCHLORIDE 7 ALUMINUM D 8 100%METHANOL COMPATIBLE FRP <br /> 0 9 BRONZE 10 GALVANIZED STEEL D 95 UNKNOWN 99 OTHER <br /> C. INTERIOR 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING PHENOLIC LINING <br /> LINING ❑5 GLASS LINING 6 UNLINED 95 UNKNOWN V� <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES D NO 'OTHER K <br /> D. CORROSION ❑ 1 POLYEPILENEWRAP 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 95 UNKNOWN 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 NONE A U 5 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 SERGLASSPIPE A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUM A6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION YSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> D` ✓ P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> /y S 6 PRECISION TESTING S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN <br /> P 5 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MO/VR) 2. ESTIMATED QUANTITY OF <br /> SUBSTANCE REMAINING IN 3. WAS TANK FILLED WITH <br /> OALLONB INERT MATERIAL? DYES 0 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRaCT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# <br /> mFACILITY ID X TANK ID# <br /> 3 � = Olt o ao v � <br /> CURRENT LOCAL AG�jEICY FACILITY IO# APPROVED BY NAME <br /> . A N `�}A f� 5 PRONE#WITH AREA CODE <br /> PERMIT NUMBER d v (/ PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE <br /> CEIPT# BY. , <br /> FORM S S-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY / <br />