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STATE OF CALIFORNIA . WATER RESOURCES FCONTROL BOARD „:, •, <br /> FORM 'B': UNDERGROUND STORAGE TANK PROGRAM =moma <br /> TANK TANK PERMIT APPLICATION INFORMATION o <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. `' rte '' Z <br /> MARK ONLY ❑ 1 NEW PERMFr 3 RENEWAL PERMIT { , <br /> ❑ CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED ' <br /> FACIL#TY/SITE NAME WHERE TANK IS INSTALLED: ���� / <br /> !� - FARM TANK-YES❑ NO 4hk <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPE FY C3'1 <br /> A. OWNERS TANK ID q U B. NAANUFACTURED BY: �� <br /> C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Q <br /> II. TANK 92NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D- <br /> A. CZ'I MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. E] 2 <br /> 1 UNLEADED LEADED ❑3 DIESEL <br /> F-13 CHEMICAL PRODUCT F-1B.4 OIL 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL 6 AVIATION GAS' <br /> ❑5 HAZARDOUS ❑ BD EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑i METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM 0,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF /A <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.0 /f/ 191— C.A.S.N: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER LJNKNDWN <br /> SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER <br /> F-11 STEELIIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLADWIFIBERGLASSREINFORCED PLASTIC <br /> B.TANK ❑S CONCRETE ❑ 6 YNNYLCHLORIDE ❑�95UNKNOWN <br /> NUM ❑g 10095 METHANOLCOAIPATIBLEFRP <br /> ti MATERIAL <br /> ❑9 BRONZE LVANIZEDSTEEL ❑99 OTHER <br /> ❑ 1 RUBBER LINED 2 A LINING ❑ 3 EPDXY LINING ❑4 PHE ING <br /> C. IN�RfOR <br /> UIQ NG ❑5 GLASS LINII 6 UNLINED UNKNOWN <br /> ❑15 G A L A WITH 10095 METHANOL? []YES ❑NO <br /> ❑99 OTHER <br /> �. CORROSION ❑ 1 PO WRAP ❑ 2 TARORASPHALT EZUNKNt <br /> 4 RBERGLASSREINFORCEDPLASTIC <br /> PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑ 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 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 A U 6 CONCRETE A7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A 9 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 S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION.ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1.ESTIMATED DATE LAS7US D(MO/YR) 2ESTIMATED QUANTITY OF 3.WAS TANK FILLEDWITH <br /> SUBSTANCE REMAINING IN INERT MATERIAL? <br /> GALLONS ❑YES ❑ NO <br /> THIS FORM HAS FIEIV COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) - DATE - <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION# AGENCY 8 FACILITY ID A TANK ID N <br /> EE -:1 EE Li Lob I / I �cll- Edo 1 �111 <br /> CURRENT LOC L AGENCY FACILITY ID 8 APPROVED Y ME PHONE 6 WITH AREA CODE <br /> �%2 Z <br /> LPERMIT NUMBER PERMIT APPROVAL DATE PERMIT E RATION DATE <br /> .R PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT 8 BY: <br />} FORM 6(6-29-88) THIS FORM MUST BE ACCOMPANIED%,dFACILITY/SITE APPLICATION, FORM 'A',UNLESS A 6"UNT FORMA' HAS BEEN FILED <br />