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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'B': UNDERGROUND STORAGE TANK PROGRAM "' <br /> IN <br /> TANK '" 'TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING I RMATION FOR EACH TANK. <br /> MARK ONLY ❑ I NEW PERMIT 0 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM 2 INTERIM PERMIT E] 1 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED /0-)7-) <br /> FACILITY/BITE NAME WHERE TANK 18 INSTALLED: �551 �G.r.r c A FARM TANK-YES D NO LD <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-If UNKNOWN-80 SPECIFY <br /> A OWNERS TANK IDE _-j,C? B. MANUFACTURED BY: <br /> C.YEAR INSTALLED C D. TANK CAPACITY IN GALLONS: <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(At),IS NOT MARKED,COMPLETE ITEM D. <br /> A I 70fl VEHICLE FUEL 2 PETROLEUM 8. C. ❑ 1 UNLEADED 0 2 LEADED 7 DIESEL <br /> D CHEMICAL PRODUCT 1 OIL 1 PRODUCT ❑A GASAHOL O 5�rFUEL 6 AVIATION GAS <br /> 5 HAZARDOUS BO EMPTY 95 UNKNOWN 2 WASTE D 1 METHANOL L01 99 OTHER(DESCRIBE IN ITEM D.BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED 8 C.A.S.I y o C.A.S.N: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.A D <br /> A. TYPE OF ❑ IWALLED E]0 SINGLE WALLED MTH EXTEROR LINER 95 UNNOVRI <br /> SYSTEM 2 SINGLE WALLED A SECONDARY CONTAINMENT 99 OTHER <br /> I STRURON 2 STAINLESS STEEL 7 RBERWSS 1 STEEL CLAD WIF18ERGLASS REINFORCED PLASTIC <br /> B.TANK 5 mcwm 6 PMYWM1.CNL0(NOE 1 ALUMIUM 61 OL COMPATIBLE ERP <br /> MATERIAL ❑9 BRONZE 10 GALVANIZED STEEL E] 95 UNKNOWN Oona <br /> C.INTERIOR Ell RUBBER LINED ❑2 UNING 0 EPDXY UMNG ❑ 1 PHENOLIC UNNG <br /> LINING [DS GLASS UNNG 6 LIMNED ❑ 95 UNKNOWN <br /> E]IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑ NO E]99 OTHER <br /> D. CORROSION ❑ 1 POLYEI)LENEWPAPI�2Jp )R ASPHALT �T WNIL WRAP 1 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION S CATHODIC PROTECTION L` n 991 NONE 095 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 0 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B.CONSTRUCTION A SINGLE WALLED A U 2 DOUBLE WALLED A U 9 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> A U I STEEL/IRON A U 2 STAINLESSSTEEL A U 0 POLYVINYL CHLORIDE(PVC) A U A FIBERGLASS PIPE A U 91 NONE <br /> C.MATERIA. A U 5 ALUMINUM A U a CONCRETE A U 7 STEELCLAD W/FRP A U a 10091 METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZEDSTEEL 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 I VISUAL CHECK P 6 2 INVENTORY RECONCILIATION P A 7 VADOSE WELLS P 9 1 ELECTRONIC MONITOR P a 5 GROUND WATER MONITORING WELLS <br /> NN I t. 6 PRECISION TESTING P t 7 PRESSURE TESTING P ! 91 NONE P t 95 UNKNOWN ► t 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTHN OF 0.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN INEFlT MATERIAL] [_-]YES [:] NO <br /> GALLONS <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT. <br /> APPLICANT'5 NAME(PRINTED 6 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION I AGENCY I FACILITY ID E TANK ID E <br /> = U-1-1 I v 1 o / 7 TF/ I o I v lo <br /> CURRENT LOCAL AGENCY FACILRY ID I APPROVED BY NAME PHONE I WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHIC KI PERMIT AMOUNT SURCHARGE AMT. FEE COD! RECEIPT By- <br /> III _j <br /> {fN1M R IA.29.M1 THIP TORY YllpT pF If•MYBIYI[n BVI[Inl ITV,e,Tt IMr Irinnu 611011 <br /> ;A rm e..•wunnem .......... .......... ...... (/'C <br />