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' <br /> STATE OF CALIFOR� ljb WATER RESOURCES CONTF <br /> FORM `B'; UNDtERGROUND STORAGE TANK PRI)4 JOARD RAM <br /> TANK PERMIT APPLICATION INFORMATION <br /> TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> I NEW PERMIT F-] 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENT ;K <br /> MARK ONLY El I R OV� <br /> ONE ITEM 2 INTERIM PERMIT El 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVE <br /> N <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: L/O f-, Ar;&.) FAPRMTANK-YESE] z <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A, OWNERS TANK 10# S. MANUFACTURED BY: <br /> CAPACITY <br /> Y ING <br /> ALLONS: <br /> D. TANK CAPACC IT <br /> C. YEAR INSTALLED Ale- <br /> 11. TANK CONTENTS IF(A.1).IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D 00 <br /> A. <br /> C. 1 UNLEADED EK2 LEADED 3 DIESEL <br /> ffl'MOTOR VEHICLE n 2 PETROLEUM B. 4 GASAHOL 5 JET FUEL ❑ 6 AVIATiON GAS <br /> F-] 3 CHEMICAL PRODUCT 4 OIL B. PRODUCT 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> F-] 5 HAZARDOUS 80 EMPTY 0 95 UNKNOWN 2 WASTE <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C'A'S'4: <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.9 <br /> L_ <br /> xill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,8,C,&D <br /> A.TYPE OF F__j j DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM t�2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> STEELIIRON 71 2 57AINLESS STEEL 0 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC. <br /> B.TANK rV 5 CONCRETE 6 POLYVINYLCHLORIDE F-1 7 ALUMINUM ❑8 100%METHANOL COMPATOLEFRP <br /> MATERIAL LJ <br /> 9 BRONZE 10 GALVANIZED STEEL [:]M UNKNOWN 99 OTHER <br /> 0 I RUBBER LINED F-1 2 ALKYD LINING F-1 3 EPDXY LINING [:]_PKENOLIC LINING <br /> C. INTERIOR D 5&ASSUNING F] 6 UNLINED m 95 UNKNOWN <br /> LINING F-I IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? E]YES 0 NO 99 OTHER <br /> D.CORROSION 1 poLyErHUENEWRAP F__j 2 TAR OR ASPHALT F__] 3 L WRAP 4 F18ERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHOOICPROTECT10N 0 91 NONE EI95 UNKNOWN El 99 OTHER <br /> IV. PIPING INFORMA)RON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A�Ujl SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A tU795 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESS STEEL A I U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE <br /> C. MATERIAL A U 5 ALUMINUM A ^6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 5 UNKNOWN A U 99 OTHER <br /> LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> 1 VISUAL C Kup S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> p A 6 PRECISIONTESTING P S 7 PRESSURETESTING P 5 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> A T'ANKF ED WITH <br /> IL <br /> 1. ESTIMATED DATE LAST USED(MU/YR) 2. ESTIMATED OUANTWY OF 3.WAS TANK FILLED WITH <br /> T, , L' <br /> INERT MATERIAL?SUBSTANCE REMAINING IN GALLONS_ O�YES 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) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY* JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> rl 1 :1 1 _Ll FoT �I -Z 1 !6 ol <br /> CURRENT LOCAL AGENCY FACILITY 10# APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK# <br /> PERMIT AMOUNT <br /> SURCHARGE AMT. FEE CODE RECEIPT# BY. <br /> 'A! FI E I A43 <br /> FORM B(3-7-98) THIS FORM MUST BE ACCOMPANIED dY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A vallRENT FORM HAS BEEN L D <br /> DATA PROCESSING COPY <br />