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STATE OF CALIFORNIJ WATER RESOURCES CONTR OARD <br /> FORM B': UND GROUND STORAGE TANK PR(RAM <br /> TANK TANK PERMIT APPLICATION INFORMATION Vim . <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> E <br /> ;;Eo <br /> I NEWPERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION , f`a <br /> 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE �7 PERMANENTLY CLOSED TANK (C) <br /> WHERE TANK IS INSTALLED: Q� ❑B TANK REMOVED <br /> tw FARM TANK-YES E NO Lrl <br /> I. TANK DESCRIPTION COMPLETE ALL ITE WS-IF UNKNOWN—SO SPECIFY IV <br /> A. OWNERS TANK IO p <br /> B. MANUFACTURED BY: <br /> C.YEAR INSTALLED <br /> D. TANK CAPACITY IN GALLONS: <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A7),IS NOT MARKED,COMPLETE ITEM D. <br /> A. ❑ I MOTOR VEHICLE FUEL 2 PETROLEUM B. C. 1 UNLEADED <br /> 3 CHEMICAL PRODUCT 4 OIL L_j ❑2 LEADED 3 DIESEL <br /> 1 PRODUCT 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS 80 EMPTY 0 95 UNKNOWN E] 2 WASTE L] 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# <br /> C.A.S.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&o <br /> A TYPE OF ❑ 1 DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2SINGLEWALLED 4 SECONDARY CONTAINMEM El <br /> N OTHER <br /> B. TANK 1STEELPRON 2 STAINLESS STEEL 3FIBERGLASS 4STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL El 5 CONCRETE 00 ❑6 POLYVINYLCHLORIDE 0 7 ALUMINUM 8 100%MEIHANOL COMPARBLEfgP <br /> 9 BRONZE 10 GALVANIZED MEL %UNKNOWN 99 OTHER <br /> C. INTERIOR ❑ 1 RUBBER LINED 0 2 ALKYD LINING [3 EPDXY LINING 4 PHENOLIC LINING <br /> LINING ❑5 GLASS LINING 6 UNLINED <br /> 95 UNKNOWN <br /> D ISUNING MATERIAL COMPATIBLE WITH 10D%METHANOL? YES 0 NO 99 OTHER <br /> D. CORROSION ❑ 1 POLYETHLENE WRAP ED2 TAR OR ASPHALT 3 VINYL WRAP <br /> PROTECTION ❑4 TIBERGLASS REINFORCED PLASTIC <br /> 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE 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 <br /> B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 <br /> A U 1 STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE OTHEfl <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP <br /> A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM <br /> UAL CHECK MUST BE CIRCLED. <br /> P 8 1 VISP 5 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER <br /> VI, INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF <br /> SUBSTANCE REMAINING IN 3.WAS TANK FILLED WITH <br /> GALLONS INERT MATERIAL? []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) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION# AGENCY# FACILITY ID# <br /> TANK ID# <br /> HE 6EITR <br /> CURRENT LOCAL AGENCY FACILITY ID M <br /> 4 D APPROVED BY NAME n PHONE p WITH AREA CODE <br /> PERMITNUMBER K / 3 <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK# PERMIT AMOUNT SU ARICE AMT. <br /> FEE CODE REC k <br /> BY: <br /> FORM B(6.29-88) THIS FORM MUST BE ACCOMPANIED BY A ACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />