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STA-riEOF CALII=OTIA WATER RESOURCES CO"L BOARD .. <br /> FORM 'B': UNDE"ROUND STORAGE TANK PROk-.--4AM <br /> 'ASK TANK PERMIT APPLICATION INFORMATION <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 P ANENTLY CLOSED TANK <br /> ONE ITEM E]2 INTERIM PERMIT E]4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE TANK REMOVED D <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: St� nRM TANK-YES NO (� <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK ID p B. MANUFACTURED BY: (� <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: <br /> 11. TANK C ENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,CO ETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. �PRODUCTC. 1 UNLEADED �2 LEADED 3 DIESEL <br /> 3 CHEMICALPRODUCT 4 OIL M 4 GASAHOL [:]5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS 80 EMPTY [::]95 UNKNOWN E]2 WASTE 0 7 METHANOL E]99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF �� C.A.S. <br /> HAZARDOUS SUBSTANCE STORED 8 C.A.S.q .A.S.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF ❑ 1 ALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM L tf 2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEELARON 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK <br /> MATERIAL 5 CONCRETE 6 POLYVINYL CHLORIDE O 7 INUM 8 100%METHANOL COMPATIBLE FRP <br /> 9 BRONZE E] 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> C.INTERIOR <br /> 1 RUBBER LINED Q 2 ALKYD LINING 3 EPDXY LINING E]4 P LIC LINING <br /> LINING ❑5 GLASS LINING �6 UNLINED 95 UNKNOWN <br /> E]IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? Ej YES [:] NO [:]99 OTHER <br /> D.CORROSION ❑ I POLYETHLENE WRAP 2 TAR OR ASPHALT 3 VLWL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE 1 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 A95 UNKNOW 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.LIATERIAL 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 U 95 UNKNO N 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 3 3 VADOSE WELLS P 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 /> 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING INGALLONS INERT MATERIAL? YES 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 N FACILITY ID N TANK IO M <br /> CURRENT LOCAL AGENCY FACILITY ID JI APPROVE PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK N PERMIT AMOUNT ,SURCHARGE AMT. FEE CODE [_RECEIPT x BY: <br /> 24 <br /> FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />