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STATE OF CALIFORNOb WATER RESOURCES CONTRSPARD <br /> FORM 'B': UNDERGROUND STORAGE TANK PROGRAM m' <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ---- <br /> MARK ONLY ❑1 NE'NPERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM ❑ 21NTERIMPERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED <br /> -iy ( FARM TANK-YES❑ NO ❑ <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY V <br /> A. TANK ID k <br /> B. MANUFACTURED BY: <br /> . OW <br /> D. TANK CAPACITY IN GALLONS. <br /> C. YEAR INSTALLED <br /> II. TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE <br /> ITELEADED <br /> 6 AVIATION GAS <br /> M D. ❑3 DIESEL <br /> 6' IUNLEADED <br /> A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM I <br /> E] 6v 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑ 4 GASAHOL El5 JET FUEL ❑ <br /> ❑ 5 HAZARDOUS ❑ 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.W <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# <br /> Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> 1 OUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN <br /> A TYPE OF ❑ 2 S ❑99 OTHER <br /> SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT <br /> ❑ I STEELIIRON ❑ 2 STAINLESS STEEL (LSI 3 FIBERGLASS ❑ 4 STEEL CLAD WIRBERGLASS REINFORCED PLASTIC <br /> B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLEFRP <br /> MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER <br /> ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING n 4pEN000 UNING <br /> C. INTERIOR ❑ 5 GLASS LINING ❑6 UNLINED lLr9595 UNKNOWN <br /> LINING <br /> ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 99 OTHER <br /> D.CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2TAR OR ASPHALT ❑ 3 LWRAP ❑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 A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B. CONSTRUCTION AU 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE 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) A U 4 FIBERGLASSPIPE A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 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 1 VISUAL CHECK P 'S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> p 1S 6 PRECISION TESTING P S 7 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? E]GALLONS <br /> ❑ 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# l FACILITY ID# TANK ID# <br /> CURRENT LOCAL AGENCY FACILITY ID N <br /> APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PER MIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK PERMIT AMOUNT AL SURCHARGE AMT. FEE CODE ECEIPT# BY: <br /> FORM B(6-29-88) THIS FORM MUST BE ACCOMPAN BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESSIMRENT FORMA' HAS BEEN FILED <br /> FILE COPY <br />