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s> 1 14r h <br /> STATE OFCALIFORN& WATER RESOURCES CONTR <br /> - <br /> FORM 'B': UND GROUND STORAGE TANK PR EIV <br /> TANK TANK PERMIT APPLICATION INFORMATIO ''II'' (� q 1 1 <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FORkC�TANK. <br /> MARK ONLY 1 NEW PERMIT F-]3 RENEWAL PERMIT 5 CHANGE OF INFOLD p[ n�' TkY CLOSED TANK <br /> ONE ITEM E-12 INTERIM PERMIT El 4 AMENDED PERMIT TEMPORA K CLOSURL�-I IV'I ��EMO ED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: She11 Station— Kf-r Li k i)_ FARM TANK- NO <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY <br /> A. OWNERS TANK ID# Unknown B. MANUFACTURED BY: <br /> C. YEAR INSTALLED 199f D. TANK CAPACITY IN GALLONS: 12, 000 <br /> 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. M� <br /> A. 1 MOTOR VEHICLE FUEL F—] 2 PETROLEUM B. C.fl UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT 4 OIL 1 PRODUCT 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS 80 EMPTY �95 UNKNOWN 2 WASTE 7 METHANOL Ej 99 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 /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF 1 DOUBLE WALLED F-1 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM [:]2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEEL/IRON 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK 5 CONCRETE <br /> MATERIAL 6 POLYVINYLCHLORIDE F-17 ALUMINUM 8 100%METHANOL COMPATIBLE FRP <br /> 9 BRONZE 10 GALVANIZED STEEL [:]95 UNKNOWN 99 OTHER <br /> C.INTERIOR 1 RUBBER LINED 2 ALKYD LINING F-13 EPDXY LINING 4 PHENOLIC LINING <br /> LINING ❑5 GLASS LINING 6 UNLINED 95 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES E] NO E—]99 OTHER <br /> D.CORROSION ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 91 NONE El 95 UNKNOWN [—]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 ATU)2 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 U 95 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 A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A 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 S 1 VISUAL CHECK P 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 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? YES F--] NO <br /> THIS FORM HAS BEEN 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# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> I [aU 01 <br /> CURRENT IH�l <br /> LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: <br /> FORM B(6-29-88) THIS FORM MUST BE ACCOMPAIND BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS IWRENT FORM`A' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />