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STATE OF CALIFOR WATER RESOURCES CONTFOOARD <br /> FORM 'B': UNDERGROUND STORAGE <br /> TANK PERMIT APPLICATION INFORMATION <br /> TANK <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK <br /> MARK ONLY ❑1 NEW PERMIT ®3 RENEWAL PERMIT r-1 5 CHANGE OF INFORMATION i CAMANENTLY CLOSED TANK <br /> ONE ITEM ❑2 INTERIM PERMIT 4 AMENDED PERMIT F-1 6 TEMPORARY TANK CLOSURE LlfeTANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS IF UNKNOWN—SO SPECIFY ` <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: " <br /> O.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: se.� <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. [:] 1 MOTOR VEHICLE FUEL ® 2 PgROLEUM B. C. E] 1 UNLEADED F-�2 LEADED F 3 DIESEL <br /> ®3 CHEMICAL PRODUCT OIL r7 1 PRODUCT ❑4 GASAHOL ®5 JET F 6 AVIATION GAS <br /> ®5 HAZARDOUS 80 EMPTY [:]95 UNKNOWN WASTE ❑ 7 METHANOL 9 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: <br /> xlll. TANK CONSTRUCTION MARK ONE ITEM ONLY IN Box A,B,C,&D <br /> A.TYPE OF ❑ 1 LE WALLED F-�3 SINGLE WALLED WITH EXTERIOR LINER ®95 UNKNOWN <br /> SYSTEM 2 SING ALLED ®4 SECONDARY CONTAINMENT E-]99 OTHER <br /> 1 STEEL/IRON 2 STAINLESS STEEL ®3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK ❑ 5 CONCRETE F--j 6 POLYVINYLCHLORIDE ®7 ALUMINUM F-]8 100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> 9 BRONZE ❑ 10 GALVANIZED STEEL ®95 UNKNOWN [:]99 OTHER <br /> it <br /> C.INTERIOR 1 RUBBER LINED ®2 LINING ❑3 EPDXY LINING ®4 PHENOLIC LINING <br /> LINING ❑ 5 GLASS LINING ffJ41UNLINED ®95 UNKNOWN <br /> IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ®YES ❑NO 99 OTHER <br /> D.CORROSION ❑ 1 POLYETHLENEWRAP M91 <br /> 2 T RASPHALT �3 VINYL WRAP �4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑5 CATHODIC PROTECTION NONE ❑95 UNKNOWN ❑99 OTHER <br /> IV. PIPING INFOR ATI N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A.SYSTEM TM A USUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A&,45 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 <br /> C.MATERIAL A U 5 ALUMINUM A 6 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 /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR 8 FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P 3 .1 VISUAL CHECK P 3 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P $ 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P 'S 6 PRECISION TESTING P $ 7 PRESSURETESTING 91 NONE P $ 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED OUANTITY OF 3,WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? F-]YES [:] NO <br /> THIS FORM HAS BEEN 40AAPI ETED 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# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> 1 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY E PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMVEXPORATIQKDATE <br /> CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE lal <br /> EIPT <br /> k <br /> FORM B(3-7-8B) THIS FORM MUST BE ACCON I A FACILiT1flSITE PLICATION, ` ',UNLESSRENT FOR 'A' HAS BEEN FILED <br /> DATA PROCESSINGCOPY <br />