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( , <br />STATE OF CALIFORNI WATER RESOURCES CONTRO ARD <br />5E�'ioii'Yf' <br />FORM 'B': UNDE ROUND STORAGE TANK PRO AM' <br />.o <br />T A AI v TANK PERMIT APPLICATION INFORMATION -_ m <br />COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. '- <br />MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br />ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE E] 8 TANK REMOVED Ul <br />FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK - YES [:] NO <br />I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY <br />A. OWNERS TANK ID # 0 '2-- B. MANUFACTURED BY: <br />C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Q <br />Il. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. <br />A. V1 MOTOR VEHICLE FUEL 7 2 PETROLEUM <br />B. <br />C. 0 1 UNLEADED LEADED E] 3 DIESEL <br />3 CHEMICAL PRODUCT F-] 4 OIL <br />1 PRODUCT <br />4 GASAHOL 5 JET FUEL ❑ 6 AVIATION GAS <br />❑ 5 HAZARDOUS [:D 80 EMPTY [-] 95 UNKNOWN <br />2 WASTE <br />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. # A1104 C.A.S. #: <br />Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D <br />A. TYPE OFOUBLE <br />A <br />WALLED <br />3 SINGLE WALLED WITH EXTERIOR LINER <br />[-]95 UNKNOWN <br />SYSTEM <br />3 GRAVITY A U 91 NONE <br />2 SINGLE WALLED <br />Ej 4 SECONDARY CONTAINMENT <br />A <br />99 OTHER <br />A <br />1 STEEL/IRON <br />2 STAINLESS STEEL <br />❑ 3 FIBERGLASS <br />❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br />B. TANK <br />5 CONCRETE <br />6 POLYVINYLCHLORIDE <br />❑ 7 ALUMINUM <br />8 100% METHANOL COMPATIBLE FRP <br />MATERIAL <br />Ej 9 BRONZE <br />10 GALVANIZED STEEL <br />❑ 95 UNKNOWN <br />99 OTHER <br />U 5 ALUMINUM <br />1 RUBBER LINEDn <br />2 ALKYD LINING <br />�3 EPDXY LINING <br />4 PHENOLIC LINING <br />C. INTERIOR <br />LINING <br />❑ <br />6L INED <br />U 9 GALVANIZED STEEL A <br />95 UNKNOWN <br />A <br />❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? <br />❑ YES [-] NO <br />99 OTHER <br />D. CORROSION <br />❑ 1 POLYETHLENE WRAP <br />F-1 2 TAR OR ASPHALT <br />F-� 3 VINYL WRAP <br />4 FIBERGLASS REINFORCED PLASTIC <br />PROTECTION <br />[:] 5 CATHODIC PROTECTION <br />❑ 91 NONE <br />F-,fL856NKNOWN <br />99 OTHER <br />IV. <br />P'ININU INI-UKMA 1 PUN CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE <br />A. SYSTEM TYPE <br />A <br />1 SUCTION <br />A <br />e12 PRESSURE <br />A U <br />3 GRAVITY A U 91 NONE <br />A U 95 UNKNOWN A U 99 OTHER <br />B. CONSTRUCTION <br />A <br />1 SINGLE WALLED <br />w <br />A <br />U 2 DOUBLE WALLED <br />A <br />U 3 LINED TRENCH A U 91 NONE <br />A U 95 UNKNOWN A U 99 OTHER <br />A <br />U 1 STEEL/IRON <br />A <br />U 2 STAINLESS STEEL <br />A <br />U 3 POLYVINYL CHLORIDE (PVC) A U <br />4 FIBERGLASS PIPE A U 91 NONE <br />C. MATERIAL <br />A <br />U 5 ALUMINUM <br />A <br />CONCRETE <br />A <br />U 7 STEEL CLAD W/FRP A U <br />8 100% METHANOL COMPATIBLE FRP <br />RECEIPT # <br />A <br />U 9 GALVANIZED STEEL A <br />U 95 UNKNOWN <br />g <br />A <br />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 1 VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br />P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br />VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br />J <br />1. ESTIMATED ATE LAST USED (MO/YR) <br />2. ESTIMATED O ANTITY OF <br />3, WAS TANK ILLED WITH <br />w <br />SUBSTA C WAMININGIN <br />INER M E IAL? E] YES [-]NO <br />1 <br />,+�FACILITY <br />I v1� �'(✓ <br />GALLONS <br />AGE'N^CY F� ILITY <br />E <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF P11RJURY, AND TO THE BEST OF MY KNOWLEDd E, IS TRUE AND CORRECT. <br />APPLICANT'S NAME (PRINTED & SIGNATURE) DATE <br />LnCAL AGENCY USE nNLY <br />JURISDICTION # <br />AGENCY # <br />ID # <br />TANKID# <br />[�lll I I 1 -1 <br />E[ <br />,+�FACILITY <br />I v1� �'(✓ <br />v <br />AGE'N^CY F� ILITY <br />E <br />AP��Y NAMFj � <br />ht <br />PHONE #WITH AREA CODE <br />I <br />40 <br />19 <br />I <br />PE/REMIT A PROVAL DATE <br />PERMIT EXPIRATION DATE <br />[/"PERMIT <br />AMOUNT <br />I.S.URCHARGE AMT. <br />FEE CODE <br />RECEIPT # <br />BY:, <br />FORM B (6-29-88) THIS FORM MUST BE ACCOMPANIED—BY A FACILITY/SITE APPLICATION, FORM `A', UNLESS A =ENT FORMA' HAS BEEN FILED <br />DATA PROCESSING COPY <br />