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STATE OF CALIFOIJ1O WATER RESOURCES COh I 410WARD <br /> FORM B': UNDERGROUND STORAGE TANK PRO RAM <br /> TANK COMPLETEAAN KPERM�T�APPITH HEC�AT�ION INFORMATIONWING I � SOR ACHrANK. <br /> EMARK <br /> EMY ;01;,NEW ;IS <br /> 0 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION MIT 4 AMENDED PERMIT ❑ 7 PERMANENTLY CLOSED TANK 1O <br /> 6 TEMPORARY TANK CLOSURE 1 TANK REMOVEDSITE NAMENSTALLED: S` I'�� <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN— FARM TANK-YES NO CJI <br /> SO SPECIFY N <br /> A. OWNERS TANK ID# -&� TU <br /> B. MANUFACTURED BY: 4 <br /> C. YEAR INSTALLED W <br /> D. TANK CAPACITY IN GALLONS <br /> II. TANK CONTENTS IF IRA),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL 0 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED 3 DIESEL <br /> 0 3 CHEMICAL PRODUCT E] 4 OIL <br /> B0 EMPTY 95 UNKNOWN 2 PRODUCT <br /> ODECT ci 4 GASAHOL D 5 JET FUEL 0 6 AVIATION GAS <br /> 5 HAZARDOUS 7 METHANOL E] 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.N <br /> 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D C.A.S.H: <br /> [::7M <br /> ❑ I UOU8LE WALLED �3 SINGLE WALLED WITH EXTERIOR LINER <br /> 2 SINGLE WAILED 4 SECONDARY CONTAINMENT ❑ 95 UNKNOWN <br /> 99 OTHER <br /> ❑ I STEEL/IRON �2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> L 5 CONCRETE 6 POLYVINYLCHLORIDE 7 ALUMINUM 8 100%METHANOL COMPATIBLE FRP <br /> 0 9 BRONZE 10 GALVANIZEDSTEEL 95 UNKNOWN 99 OTHER <br /> R ❑ 1 RUBBER LINED �2 ALKYD LINING �3 EPDXYLINING 4 PHENOLIC LINING <br /> ❑5 GLASS LINING 0 6 UNLINED 95 IS LINING MATEFlIAL COMPATIBLE WITH 10096 METHANOL? g ND gg OTHERWNION ❑ I POLYETHLENEWRAP 2 TAR ORASPHALT 3 VINYL WRAP ❑ION 0 5 CATHODIC PROTECTION 0 91 NONE ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> 0 95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A WABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE <br /> B. CONSTRUCTION A U 1 SINGLE WALLED A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 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 U 6 CONCRETE <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U ] STEEL CLAD W/FRP A U 8100%METHANOLCOMPATIBLE FRP <br /> A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,q PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P g T PRESSURE TESTING <br /> P S 91 NONE P S 95 UNKNOWN <br /> V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE P s ss OTHER <br /> 1. ESTIMATED DATE LAST USED(MO/YR) <br /> 2. ESTIMATED DUANTITY OF <br /> SUBSTANCE REMAINING IN 3. WAS TANK FILLED WITH <br /> OALLON8 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 CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> GATE <br /> LOCAL AGENCY USE ONLY <br /> `C7OU�NTYY-# JURISDICTION# AGENCY N <br /> FACILITY ID# TANK ID N <br /> CURRENT LOCAL AGENCY FACILITY ID# / <br /> /, '� APPROVED BY NAME PHONE N WITH AREA CODE <br /> PEgMIT NUMBER <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK# PERMIT AMOUNT URCHARGE AMT. <br /> FEE CODE RECEIPT# <br /> I I-BY: V <br /> FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED B A FACILITY/SITE APPLICATION, FORM `A',UNLESS A CURRENT FORMA' NAS BEEN FILED <br /> DATA PR COPY <br />