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STATE OF CALIFORN& WATER RESOURCES CONT BOARD <br /> FORM `B': UND GROUND STORAGE TANK PROGRAM <br /> TANK TANK PERMIT APPLICATION INFORMATION u�t <br /> �o <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> [FACILITY/SITE <br /> RK ONLY � 1 NEW PERMIT �3 RENEWAL PERMIT ``'LI oa„1p <br /> NE ITEM ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSEDETANK O <br /> 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT �6 TEMPORARY TANK CLOSURE <br /> NAME WHERE TANK IS INSTALLED: <br /> Z � 8 TANK REMOVED <br /> St 9fpy� FARM TANK-YES Q NO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY N <br /> A, OWNERS TANK ID 4 2 cy) <br /> B. MANUFACTURED BY: U� <br /> C. YEAR INSTALLED IJ <br /> D. TANK CAPACITY IN GALLONS: co <br /> 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL � 2 PETROLEUM g <br /> C. � 1 UNLEADED 2 LEADED <br /> Q 3 CHEMICAL PRODUCT q OIL � 3 DIESEL <br /> f v l ' PRODUCT ❑4 GASAHOL 0 5 JET FUEL 0 6 AVIATION GAS <br /> 5 HAZARDOUS e0 EMPTY 95 UNKNOWN 0 2 WASTE 7 METHANOL gg OTHER(DESCRIBE IN ITEM D,BELOWI <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> Ej HAZARDOUS SUBSTANCE STORED B,C.A.S.it <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,13,C,&D C.A.S.a: <br /> A. TYPE OF Q 1 DOUBLE WALLED Lj 3 SINGLE WALLED WITH EXTERIOR LINER <br /> SYSTEM SINGLE WALLED ❑ 95 UNKNOWN <br /> 4 SECONDARY CONTAINMENT E]99 OTHER <br /> 1 STEFUIRON 2 STAINLESS STEEL a 3 FIBERGLASS 0 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK ,,II�� <br /> MATERIAL El 5 CONCRETE 6 PDLYVJNYL CHLORIDE E] 7 ALUMINUM (� <br /> 9 BRONZE Q 10 GALVANIZED STEEL E1 95 UNKNOWN L__I 6 100% <br /> THER HANOL COMPATIBLE FRP <br /> Li.J �99 OTHER <br /> C. INTERIOR El I RUBBER LINED 0 2 ALKYD LINING E13 EPDXY LINING <br /> LINING Ej 6 UNLINED Q 4 P ENOLIC LINING <br /> 5 GLASS LINING <br /> 0 IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? Es�fM UNKNOWN <br /> YES � NO � gg OTHER <br /> I). CORROSION 0 1 POLYETHLENE WRAP 2 TAR OR ASPHALT <br /> PROTECTION 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> 5 CATHODIC PROTECTION gi NONE <br /> 5'UNKNOWN gg OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> FSYSTEM A U 1 SUCTIONU 2 PRESSUREN A U 1 SINGLE WAU 2 DOUBLE WALLED A U 3 LINEDI RENCH AU91AU 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> A U 5 ALUMINUM A U fi CONCRETE <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 7 STEEL CLAD W/FRP A U 8 104%METHANOL COMPATIBLE FRP <br /> A Q 99 OTHER � <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST <br /> P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR p 5 5 GROUNDWATER MO BECIRCLED. <br /> WELLS P S 6 PRECVSIONTESTING P S 7 PRESSURE TESTING <br /> P S 91 NONE P S 95 UNKNOWN <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE P S 99 OTHER <br /> P. ESTIMATED DATE LAST USED(MO/YRJ <br /> 2. ESTIMATED OUANTITY OF <br /> SUBSTANCE REMAINING IN 3.WAS TANK FILLED ITH <br /> GALLONS INERT MATERIAL? �YES �DNO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOVYLEbGE,I <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) S TRUE AND CORRECT. <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# <br /> AGENCY# FACILITY IDI <br /> TANK ID# <br /> 2- .3 -,7 3 E]:E� <br /> CURRENT LOCAL AGENCY FACfLITY ID# <br /> APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK# PERMIT AMOUNTI b <br /> SURCHARGE AMT. FEE CODE <br /> R IPT BY: <br /> FORM B(6-29-68) THIS FORM MUST BE ACCOMPANIED BY A. ITYISITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM`A' HAS BEi <br /> DATA PROCESSING COPY EN FILED <br />