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' ATE OF CALIFORNI WATER RESOURCES CONTROL BOARD <br /> FORM 'B': UND�ROUND STORAGE TANK PRAM <br /> QOOMPLETE <br /> TANK TANK PERMIT APPLICATION INFORMATION Z <br /> CA SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> 10 <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLO' <br /> NK <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE �,( `❑8 TANK REMOVED / W <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: $'LO `GAN Srz <br /> -FARM TANK-YES NO (� <br /> W <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK ID 4B. pywg <br /> MANUFACTURED BY: <br /> D. TANK CAPACITY IN GALLONS: $DO O <br /> Fr YEAR INSTALLED ( <br /> It. 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 F-12 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT 4 OIL PRODUCT ❑ 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS 80 EMPTY [-] 95 UNKNOWN 2 WASTE Ej 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.R: <br /> HAZARDOUS SUBSTANCE STORED 8 C.A.S.R <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,B D <br /> A.TYPE OF ❑ 1 UBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER E]95 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED F-1 4 SECONDARY CONTAINMENT 99 OTHER <br /> �STEELPRON ❑ 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC <br /> B.TANK F--] 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE F-1 7 ALUMINUM Ej B 100%METHANOL COMPATIBLE FRP <br /> MATERIAL ❑9 BRONZE F1 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED F-12 ALKYDLINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> C. INTERIOR 5 GLASS UMNG 6 UNLINED 95 UNKNOWN <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? O YES E] NO (' 90THER Il <br /> 9 <br /> D. CORROSION ❑ I POLYETHLENEWRAP � 2 TARORASPHALT 3 NYL 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 A U 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 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 B 109%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A UO 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 /> 5 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS <br /> P 9 6 PRECISION TESTING P 5 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 IN GALLONS INERT MATERIAL? YES 0 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 S SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION M AGENCY N FACILITY ID N TANK ID M <br /> I oo 03 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME �� PHONE N WITH AREA CODE <br /> o-� <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE LODE RECEIPT N BY: <br /> L FORMBI6-29-BBI THISFORM MUST BE ACCOMP ' YAFACILRY/SITE APPLICATION, FORM ' <br /> A',UNLESRRENT FORMA' HASBEENFILED <br /> DATA PROCESSING COPY <br />