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STAT ORNIA ;WATER RESOURCES CONTROL BOARD <br /> FORM B': UNDERGROUND STORAGE TANK PROGRAMML <br /> TANK TANK PERMIT APPLICATION INFORMATION 46 W" <br /> COMPLETE A SEPARATE FORMA WITH THE FOLLOWING INF MATION FOR EACH TANK. z " <br /> MARK ONLY ❑ 1 NEW PERMIT 3.RENEWAL PERMIT 1 <br /> ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED T <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMITORARY TANK CLOSURE E]6 TEMPL ❑8 TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: V FARM TANK-YES❑ NO '+ <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SOS.PECIFY <br /> A. OWNERS TANK ID# B. MANUFACTURED BY; Ln <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Uvv <br /> 11. TANK C TENTS IF(A.1),19 MARKED,COMPLETE ITEM C.IF(A.1),ISNOT MARKED,CO TE ITEM D. <br /> A. f MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑2 LEADED ❑3 DIESEL <br /> ❑3 CHEMICAL PRODUCT - [:]4 OIL PRODUCT 0 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS <br /> ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.N C.A.S.It: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,a D <br /> A.TYPE OF [:]-I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN <br /> SYSTEM ❑2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER <br /> ❑ I STEELIIRON ❑2 IN STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC <br /> B.TANK 5 CONCRETE <br /> MATERIAL E] LORIDE ❑L:j7 AL M ❑8 10046 METHANOL COMPATIBLE FRP <br /> ❑9 BRONZE LVANI STEEL UNKNOWN ❑99 OTHER <br /> ❑ <br /> c.IrOR 1 RUBBERLINED LINING ❑3 EPDXYLINING E]4 PHENOLICUNING <br /> LIH G ❑5 GLASS LINM�%ff6 UNLINEDUNKNOWN <br /> ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER <br /> 0,CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VI ❑4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑5 CATHmICPROTECTION ❑91 NONE 95 UNKNOWN ❑N OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A.SYSTEM TYPE A 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 n 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 V 5 ALUMINUM A CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A 5 UNKNOWN A U 99 OTHER <br /> LEAK DETECTION <br /> /SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED, <br /> P S 1 VISUAL CHECK l r S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS <br /> P LPRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P 9 95 UNKNOWN P 8 99 OTHER <br /> I. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1.ESTIMATED DATE LAST USED(MQ/Yq) 2. ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH <br /> aAuons - <br /> SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑NO <br /> THIS FORM HAS BEEN CO PLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,!S TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY* FACILITY fD N TANK ID N <br /> CURRENT LOC"ENCY FACILITY IDN APPROVED BY NAM PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATEPER EXPIRATI ATE <br /> T7 <br /> HECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT f BY: <br /> T a <br /> I. I <br /> FORM B(6-29-ss) THIS FORM MUST BE ACCOMPAN1EaZv 'ACILITY/SITE APPLICATION, FORM 'A',UNLESS A T" "7T' FORM W HAS BEEN FILED <br /> DATA PROCESSING COPY ` <br />