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STATE OF-CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `B': UNDERGROUND STORAGE TANK PROGRAM <br /> TANKTANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOIAiING.JNFORMATION FOR EACFf,TANK. <br /> IQ <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ Z PERMANENTLY CLOSED TAN <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: v a FARM TANK-YES❑ NO <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO aECIFY A ,A <br /> A. OWNERS TANK ID N S. MANUFACTURED BY: U&k, <br /> C.YEAR INSTALLED O. TANK C ACITY IN GALLONS: 0001 <br /> 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NbT MARKED,COMPLETE ITEM D.' <br /> A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ,{ IESEL <br /> ❑3 CHEMICAL PRODUCT 4 OIL �IPRODUCT 4 GASAHOL ❑ 5 JET FUEL 6 AVIATION GAS. <br /> ❑ 5 HAZARDOUS ❑80 EMPTY ❑ 95 UNKNOWN ❑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.N C.A.S.N: /I <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D -•. �• <br /> A TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN <br /> SYSTEM ❑2 SINGLE WALLED ❑ 4 SECONDARYOONTAINMENT ❑99 OTHER <br /> D'fSTEELIIRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASSREINFORCEDPLASTIC <br /> B.TANK <br /> MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ T ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP <br /> 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> INTI�IOF-11 RUBBER UNED E]2 ALKYD LINING ❑3 EPDXY LINING ❑ 4 PHE OLIC LINING <br /> C LINING R ❑ 5 GLASS LINING ❑6 UNLINED UNKNOWN <br /> �r ❑ IS LINING MATERIAL COMPATIBLE WITH 1W%METHANOL? YES ❑NO ❑99 OTHER <br /> D.CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT 3 VI P ❑ 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 rl 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 OUBLE WALLED A U 3 LINED TRENCH A U 91 NONE WFT95 UNKNOWN A U 99 OTHER <br /> A U I STEEL/IRON TAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C.MATERIAL A U 5 ALUMINUM NCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVA 95 KNOWN A U 99 OTHER ' <br /> :I <br /> V. LEAK DETECTION <br /> �S�YfiR� C L P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P S 1 VISUAL CHECK /P/5 TORY RECONCILIATION P 3 3 YAOOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> 5 P 6 PRECISION TESTING P S 7 P EM URE TESTING P S 91 NONE P B 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION.ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1.ESTIMATED DATE LASX�T <br /> 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,fS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED S SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> EENT <br /> JURISDICTION 8 AGENCY A FACILITY ID A TANK ID N <br /> 10101 r ol ol 11 <br /> LOCALAQEN V FACILITY IDA APPROVE T N N PHONE N WITH AREA CODE -, <br /> PERMIT APPROVAL DATE PER EXPIRATI DATE <br /> PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: <br /> ` /FORM B(B-29-88) THIS FORM MUST BE ACCOMPANIED4,.,iFACILIT7/SRE APPL[CATION, FORM'A',UNLESS A 0,.oENT FORM`A' HAS BEEN FILED <br /> ngTJ1 ^n(►/:1CCCI�ur±r�1ny <br />