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STATE OF CALIFORNIA } WATER RESOURCESCONTRO4RD `^''ti: <br /> FORM 'B': UNDER ROUND STORAGE TANK PRO AM <br /> TANKTANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING FORMATION FOR EACH TANK. Z <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOS K <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE B TANK REMOVED b W <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: 4 M Q)A S ARM TANK-YES❑ NO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY S 00 <br /> 00 <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Q <br /> 11. TANK C TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(a1),IS NOT MARKED,C MPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL 2 PETROLEUM B C. 1 UNLEADED 0 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT F-] 4 OIL IPRODUCT 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> El 5 HAZARDOUS 1:1 80 EMPTY ❑95 UNKNOWN 2 WASTE ❑ 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C A.S. <br /> HAZARDOUS SUBSTANCE STORED&C A.S.# <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A.B,C,&D <br /> A TYPE OF E] 1AUBLE WALLED Q 3 SINGLE WALLED WITH EXTERIOR LINER F--] 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED cl 4 SECONDARY CONTAINMENT ❑ 99 OTHER <br /> Eif1 STEEL/IRON ❑ 2 STAINLESS STEEL F-1 3 FIBERGLASS F-� 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK ❑ 5 CONCRETE 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ B 1 DA METHANOL COMPATIBLE FRP <br /> MATERIAL EJ <br /> 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN F-] 99 OTHER <br /> D 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING 0 4 PHENOLIC LINING <br /> C. INTERIOR ❑ 5 GLASS LINING ❑6 UNLINED Y5 UNKNOWN <br /> LINING <br /> F-� IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES [:] NO990THER <br /> D. CORROSION ❑ I POLYETHLENE WRAP [:] 2 TARORASPHALT 3 ' YL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE L��Y'/'UNKNOWN 99 OTHER <br /> IV. PIPING INFORMA ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE Aly/1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 5 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUM A6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%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 /> 8 1 VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> 65 P S 6 PRECISIONTESTING P S I PRESSURETESTING P S 91 NONE P S 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 [:] 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# JURISDICTION# AGENCY# FACILITY ID# TANKID# <br /> M1 = = 10101 / S ! S Fol o 0 <br /> CURRENT LOCAL AGENCY FA ITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> Coz <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> /�y��/J CHECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY: <br /> T <br /> ORM 8I6-29-88) THIS FORM MUST BE ACCOMPANIE Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />