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STATE OF CALIFORPS WATER RESOURCES CONT BOARD <br /> i2 FORM 'B': UND GROUND STORAGE TANK PRVGRAM Hm: <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK.----------------�( <br /> mp„ <br /> MARK ONLY ❑ 1 NEW PERMIT E 3 RENEWAL PERMIT CHANGE OF INFORMATION CLOSED <br /> T ,. <br /> ONE ITEM 7 ERMANENTLY CLOSED TANK <br /> 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: <br /> FARM TANK-YES 0 NO <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY O <br /> A. OWNERS TANK ID ui < B. MANUFACTURED BY: <br /> C. YEAR INSTALLED <br /> D. TANK CAPACITY IN GALLONS: / <br /> 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. W <br /> A. 0 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C CTI <br /> ❑ 1 UNLEADED 0 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT OIL � 1 PRODUCT 0 4 GASAHOL 0 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS 0 80 EMPTY 0 95 UNKNOWN EgeWASTE 0 7 METHANOL OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED 8 C.A.S.# !i S l' / <br /> �C V / C.A.S.#: b <br /> All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C.d D <br /> FA. PE OF ❑ 1 DOUBLE WALLED 3 SINGLEWALLEDWITH EXTERIORLINER 95 UNKNOWN <br /> STEM SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> E44TEEUIRON E]2 STAINLESS STEEL Ej3 FIBERGLASS � 4 STEEL CLAD W/FIBERGLASS REINFORCEDPLASTIC <br /> NK 0 5 CONCRETETERAL 6 POLYVINYL CHLORIDE 7ALUMINUM 08 ION METHANOL COMPATIBLE FRP <br /> E]9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> C. INTERIOR I RUBBERLINED 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> LINING ❑5 GLASS LINING 6 UNLINED �'9AUNKNOWN <br /> � IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES � NO 99 OTHER <br /> D.CORROSION ❑ 1POLYETHLENEWRAP 2TARORASPHALT n3ylNtL WRAP 4FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 91 NONE ^Lr✓ 95/UNKNOWN gg 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 9 OTHER (� <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH 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 FIBERGLASSPIPE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP <br /> A U 9 GALVANIZED STEEL A U 5 UNKNOWN A U 99 OTHER A U B 100%METHANOL COMPATIBLE FRP <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> __ _ p P S I 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 /> IW <br /> /IVC7�1'Yl. P S 6 PRECISION TESTING P S 7 PRESSURE TESTING 91 NONE P S 95 UNKNOWN p <br /> S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1 ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITV OF <br /> L1 /--/) 3. WAS TANK f,1LLE0 WITH <br /> j1/ F7 SUBSTANCE REMAINING IN ALLONS INERT MATERIAL' [:] YES O NO <br /> G <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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# II�AGENNCCY# FACILITY�Y 10# l5 <br /> `� D t � ✓ A� T�KID# <br /> (J <br /> FP <br /> NT LO AL AGENCY FACILITY ID X APPROVED BY <br /> /0// ; PHONE#WITH AREA CODE <br /> T NUMBER PERMIT APPROVAL D E PERMIT EXPIRATION DATE <br /> CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTM <br /> BY: <br /> FORM a(3-7-ee) THIS FORM MUST BE ACCOMPANIE FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CU RENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />