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STATE OF CALIFORNIA WATER RESOURCES CONTROI{'-�14RD 1y� <br /> FORM 'B': UAN RMIIT APPLICATION ND STORAGE IL INFORMATION <br /> NK PRodftm <br /> TANK TANK PE <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWIN ORMATION FOR EACH TANK. (C <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY C 0/ NK <br /> ONE ITEM INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED w <br /> Y s RM TANK-YES NO (� <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: 0 <br /> 1. TANK DESCRIPTION OMPLETEALLITEMS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK IDR B. MANUFACTURED BY: Me <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: <br /> II. TANK ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL 2 PETROLEUM B C. ❑ 1 UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT E] 4 GASAHOL ❑ 5 JET FUS' ❑ 6 AVIATION GAS <br /> 5 HAZARDOUS D 80 EMPTY ❑ 95 UNKNOWN 2 WASTE El 7 METHANOL D 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.R'. <br /> HAZARDOUS SUBSTANCE STORED&C.AS.R <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF 1DOUBLEWALLED 3 SINGLE WALLED WITH EXTERIOR LINER F-�95 UNKNOWN <br /> SYSTEM ❑2 INGLE WALLED 4 SECONDARY CONTAINMENT E] 99 OTHER <br /> 1 STEEL/IRON El 2 STAINLESSSTEEL Q 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK F-15 CONCRETE 6 POLYVINYLCHLORIDE 0 7 ALUMINUM METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> 9 BRONZE Ej 10 GALVANIZED STEEL ❑95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING ❑ 4 PHENOLIC LINING <br /> C. INTERIOR F-] 5 GLASS LINING ❑ 6 UNLINED �96 UNKNOWN <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH iW%METHANOL? F--]YES F-1NO �K99 OTHER <br /> D.CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT 3 VINYL WRAP ® 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A U 1 SUCTION 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B. CONSTRUCTION A U I SINGLE WALLED U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NON A U 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) At <br /> 4 RBERGLASS PIPE A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 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 S 1VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS <br /> P 8 6 PRECISION TESTING P S 7 PRESSURETESTING 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 3. WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? YES D 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION R AGENCY R FACILITY ID R TANK ID M <br /> ® = = lololzl9l1lcfI0 <br /> CURRENT LOCAL AGENCYFACILITYIDR� APPROVED BY NAME PHONE R WITH AREA CODE <br /> J <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK R PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPTI BY:� <br /> RE <br /> bv FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANINFY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORM'A' HAS BEEN FILED <br /> DATA PROCESSING COPY <br /> -JVfVnM OIO-[tl-WI ,nNrVnIIl A1VJl UG nYYVn,rnnlCY Dl nrnYlG1 IJIIG/VfGIVXI1Vn, II-VfIT m,V.GWJX VVnnLnl rvmmA nNJ PCCD riLCY / <br /> DATA PROCESSING COPY -/ <br />