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STATE OF CALIFORMS WATER RESOURCES CONTR ARD <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> FORM `B': -° <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EA CFI TANK. I c- <br /> 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED MARK ONLY ❑ CAS <br /> ONE ITEM ❑ 2 INTERIM PERMIT � 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE �6�ANK REMOVED <br /> �¢� FARM TANK-YES❑ NO <br /> FACILITY/SITE NAME WHERE TANK IS IN <br /> W <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 1 OD <br /> A. OWNERS TANK ID# cwc)w 1313 6b, B. MANUFACTURED BY: e hI'1 T <br /> C.YEAR INSTALLED 1 qA <br /> D. TANK CAPACITY IN GALLONS: J <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> B C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL <br /> A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM <br /> ❑3 CHEMICAL PRODUCT 4 OIL <br /> ❑ 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS <br /> ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN �3'WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF ` �l° I C.A.S.#' <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# W <br /> bAk- <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> ETANKF-� <br /> OUBLE WALLED ❑3 SINGtEWALLED WITH EXTERIOR UNER ❑ 95 UNKNOWN <br /> NGLE WALLED ❑4SECONDARI'COMAINMEM <br /> ❑99 OTHER <br /> EEL/IRON ❑2 STAINLESS BTEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> ONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ B 100%METHANOLCOMPATIBLE FRP <br /> RONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER <br /> UBBERUNED 2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING <br /> C. INTERIOR ❑ 5 GLASS LINING LINED ❑ 95 UNKNOWN <br /> LINING <br /> ❑ 16 LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES �NO OTHER <br /> D. CORROSION ❑1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT 3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION �THODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑ H OTHER <br /> IV. PIPING IF7AU9Em7EFmz <br /> CIRCLE A IF ABOVE GROUND, U IF UNDER OUND,BOTH IF APPLICABLE <br /> A.SYSTEM TTION A U 2 PRESSURE A U GRAVITY <br /> A U 91 NONE NONEA 95 UNKNOWN A U 99 OTHER <br /> B. CONSTRUGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE U UNKNOWN A U 99 OTHER <br /> EEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C.MATERIALUMINUM A 6 CONCRETE A U 7 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> LVANIZED STEEL U 5 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 S 1 VISUAL CHECK Jb S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 559GRROH NND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTI*-40 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLED WITH <br /> 1.INFORMATION <br /> LAST USED(MO/ 2. ESTIMATED OUANTITY OF INERT MATERIAL? YES ❑ NO <br /> SUBSTANCE REMAINING IN GALLONS <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 /> LOCAL AGENCY USE ONLY <br /> PPERMITNUMBER <br /> Y# JURISDICTION# TAGENCY# <br /> FACILITY ID# TANK ID# <br /> CAL AGENCY FACILITY ID# I / ,/Y�Y �1 nV�I <br /> APPROVED BY NAME PNO E k TH AREA CODE <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE Pt.�AMOUNT URCHARDE AMT. <br /> FEE CODE EIPTM BY: <br /> FORM B(6-29-68) THIS FORM MUST CCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />