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STATE OF CALIFORN� WATER RESOURCES CONTR OARD <br /> FORM 'B': UNDERGROUND STORAGE TANK PR RAM <br /> TANK PERMIT APPLICATION INFORMATION <br /> TANK ILL <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> 1 NEW PERMIT 3 RENEWALPERMIT E] 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> MARK ONLY -4- <br /> ONE ITEM 0 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE �8 TANK REMOVED <br /> Lam) ARM TANK-YES❑ NO <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: <br /> 1. TANK DESCRIPTION COMPLETE ALL ITE -IF N NOW{4 b SO SP� IFY Y� s <br /> B. MANUFACTURED BY: v� <br /> A. OWNERS TANK ID# �d <br /> C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: f.a2 <br /> II. TANK CONTENTS IF yLl),IS MARKED,COMPLETE ITEM C.IF(A,1),IS NOT MARKED,COMPLETE ITEM D. L <br /> A. 1 MOTOR VEHICLE FUEL 2 PETROLEUM <br /> B C. ❑ 1 UNLEADED 7EADEDED 3 DIESEL3 CHEMICAL PRODUCT �4 OILg PRODUCT ❑ 4 GASAHCL 6 AVIATION GAS <br /> 5 HAZARDOUS 60 EMPTY 95 UNKNOWN 2 WASTE 7 METHANOL SCRIBE IN ITEM D.BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.M <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# <br /> MI. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OFZDBUBLE WALLED 3SINGLE WALLED WITH EXTERIOR LINER <br /> 95 UNKNOWN <br /> SYSTEMGLEWALED <SECONOARY CONTAINMENT 99 OTHER <br /> :ELIIRON Ej 2 STAINLESS STEEL ❑3 FIBERGLASS El <br /> 4 STEELCLADWIFlBERGUSS REINFORCED FUSTIC <br /> B.TANKNCRETE 6 POLYVINYLCHLORIDE �7 ALUMINUM B 100%METHANOL COMPATIBLE FRP <br /> MATERIALONZE 10 GALVANIZED STEEL UNKNOWN 99 OTHER <br /> BBER UNED 2 ALKYD UNING �3 EPDXY LINING n 4�HENOUCUNING <br /> C. INTERIOR 95 UNKNOWN <br /> LININGSS UNING 6 UNLINEDNING MATERIAL COMPATIBLEWITH 100%METHANOL? E]YES 0 NO 99 OTHER <br /> D.CORROSILYETHIENEWRAP 2TAR OR ASPHALT FNNYLWRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTTHODIC PROTECTION 91 NONE LLJJ 95 UNKNOWN E199 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 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 FIBERGLASSPIPE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U S 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A 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 $ 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 /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING S 91 NONEP 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/YR) 2. ESTIMATED QUANTITY OF INERT 19(x" DYES NO <br /> SUBSTANC TNG IN GpLLONB r <br /> #: . <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE✓A/ND CORRECT. <br /> APP NTS AME(PRINTED&SIGNAT E) �r &C <br /> LOCAL AGENCY USE ONLY !� D <br /> COUNTY# JURISD� AGE <br /> FACILITY ID# TANK ID# <br /> F677 E _ � o U CSG <br /> APPROVED BY NAME PHONE#WITH AREA CODE <br /> CURRENT LOCAL AGENCY FACILITY ID# ,�� <br /> -R F M 3 % / o <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK PERMITAMOUNT SURCHARGE AMT. <br /> FEE CODE RECEIPT# BY: <br /> FORM B(3-7-SB) THIS FORM MUST BE ACCOMPANIE A FACILITYISIA APPLICATION, C DPA',UNLESS A RENT FORMA' HAS BEEN FILED <br />