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STATE OF CALIFORNIA* WATER RESOURCES CONTROL RDS'. <br /> FORM 'B': UNDERGROUND STORAGE AINFORMATION <br /> TANK TANK PERMIT APPLICANK PROIArM <br /> _ ti Z <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 10 <br /> oil <br /> [FACILITY/SITE <br /> ARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION i 7 P RMANENTLYCLO K <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT Ej 6 TEMPORARY TANK CLOSURE 6 TANK REMOVED W <br /> FARMTANK-YES[:] NO IV <br /> NAME WHERE TANK IS INSTALLED: A N <br /> gsu�s o <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS•IF UNKNOWN-SO SPECIFY (JI <br /> B. MANUFACTURED BY: <br /> A. OWNERS TANK ID# O <br /> D. TANK CAPACITY IN GALLONS: <br /> C. YEAR INSTALLED <br /> I I. 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 P ROLEUM <br /> B C. ❑ 1 UNLEADED E]2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT OIL <br /> 1 RODUCT ❑ 4 GASAHOL �5 J FUEL �6 AVIATION GAS <br /> 5 HAZARDOUS BO EMPTY 0 95 UNKNOWN WASTE 7 METHANOL 9 OTHER(DESCRIBE <br /> )INNIITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF !.!a!/. �Z / C.A.S.#: <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A TYPE OF DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM �SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEEL/IRON 2 STAINLESS STEEL � 3 FIBERGLASS 4 STEEL CUD WI FIBERGLASS REINFORCED PLASTIC <br /> B.TANK 5 CONCRETE E]6 POLYVINYLCHLORIDE 0 7 ALUMINUM 8 IN%METHANOL COMPATIBLE FRP <br /> MATERIAL ❑9 BRONZE E] 10 GALVANIZED STEEL 0 95 UNKNOWN 99 OTHER <br /> ll <br /> 1 RUBBER LINED E] 2 ALKYD LINING 3 EPDXY LINING4�PHENOLICUNING <br /> C. INTERIOR 5 GLASS LINING F�6 UNLINED 995 UNKNOWN <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES [:] NO 99 OTHER <br /> D.CORROSION ❑ I POLYETHLENEWRAP E] 2TAR OR ASPHALT V95 <br /> INYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 0 91 NONE UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UND OUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U GRAVITY A U 91 NONE A U 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 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 FIBERGLASS PIPE A U 91 NONE <br /> C.MATERIAL A U 5 ALUMINUM A A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL Airity 95 UNKNOWN A U 99 OTHER <br /> V. AK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P 3 1 VISUALCHECK P 3 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS <br /> P S 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 3.WAS TANK FILLED WITH <br /> 1.INFORMATION <br /> LAST USED(MO/YRI 2. ESTIMATED QUANTITY OF INERT MATERIAL? YES NO <br /> SUBSTANCE REMAINING IN GALLONS <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> DATE <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# <br /> FACILITY ID# TANK ID# <br /> E2t <br /> # APPROVED BY NAME PHONE#WITH AREA CODE <br /> �! 0 PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> NT SURCHARGE AMT, FEE CODE ECEIPT# BY: <br /> FORM B IS29.88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE <br /> DATAAPPLICATION, <br /> FORM <br /> COPY UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> J <br /> NG <br />