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STATE OF CALIFORNIP WATER RESOURCES CONTRO ARD <br /> FORM `B': UNDERGROUND STORAGE TANK PRO A M ��: .- <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. o <br /> MARK ONLY ❑ 1 NEW PERMIT �"''°y,. 2 <br /> ONE ITEM ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION I C <br /> 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 7 PERMANENTLY CLOSED TANK <br /> 0 6 TEMPORARY TANK CLOSURE [j 8 TANK REMOVED O <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED:?633 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN- T1. u N FARM TANK-YES 0 NO W <br /> ►V <br /> A. OWNERS TANK ID# SO SPECIFY <br /> 2 <br /> C. YEAR INSTALLED <br /> B. MANUFACTURED BY:D. TANK CAPACITY IN GALLONS: <br /> � <br /> � D <br /> II. TANK ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),S NOT MARK D,COMPLETE ITEM D. <br /> A 1 MOTOR VEHICLE FUEL 2 PETROLEUM <br /> �B�' / C 1 UNLEADED 2 LEADED <br /> 3 CHEMICAL PRODUCT �q OIL 3 DIESEL(� <br /> 5 HAZARDOUS 80 EMPTY []95 UNKNOWN I'VI1 PRODUCT 4 GASAHOL 5 JET FUEL <br /> 6 AVIATION GAS <br /> D. IF N07 MOTOR VEHICLE FUEL,ENTER NAME OF 2 WASTE 7 METHANOL ED 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# <br /> 111. TANK CONSTRUCTION MARK ONE ITEM ONLY CAS #: <br /> A TYPE OF ❑1 DOUBLE WALLED L-j 3 SINGLE WADED WITH EXTERIOR LINER <br /> SYSTEM 2 SINGLE WALLED ❑ E] 95 UNKNOWN<SECONDARY CONTAINMENT E] <br /> B9 OTHER <br /> B. TANK 1 STEEUIRON 25TAINLESS STEEL 1:1 3 FIBERGLASS 1 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC <br /> MATERIAL El 5 CONCRETE ❑6 POLYVINYLCHLORIDE 7 ALUMINUM <br /> 11 9 BRONZE 10 GALVANIZED STEEL g5 UNKNOWN 10096 METHANOL COMPATIBLE FRP <br /> OTHER <br /> C. INTERIOR 13 RUBBERUNED 2ALKYD LINING 3EPDXYY LINING �4PHENOLIC LINING <br /> LINING ❑5 GLASS UNING 6 UNUNm <br /> 0 IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑9 UNKNOWN <br /> YES �NO � OTHER <br /> D.CORROSION ❑ 1 POLYETHLENEWRAP 2 TAR OR ASPHALT <br /> PROTECTION ❑3 VINYL WRAP 4 FIBERGLASS REINFORCED PUSTIC <br /> 5 CATHODIC PROTECTION El 91 NONE 95 UNKNOWN <br /> OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A U 1 SUCTION <br /> B.CONSTRUCTION A U 1 SINGLE WgLLED A U 2 PRESSURE A U 3 GRAVITY q U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> 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 CH ORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUM <br /> A U 6 CONCRETE A U 7 STEEL CLAD W FRP <br /> A U 9 GALVANIZED ST EEL A U 95 UNKNOWN A U S 100%METHANOL COMPATIBLE FRP <br /> 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 /> ,�•yLTJ P S 6PRECISON TE P S 2INVENTORY RECONCILIATION P $ 3VADOSE WELL P 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P 8 6 PRECISION TESTING P g 7 pRES6URE TESTING <br /> P S 91 NONE 4-1095 UNKNOWN P S 99 OTHER- <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MO/YR) <br /> 2. ESTIMATED QUANTITY OF <br /> SUBSTANCE REMAINING IN 3. WAS TANK FILLED WITH <br /> ALLONS 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) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> CCOU�NT(.Y./�# JURISDICTION# AGENCY# <br /> FACILITY ID# TANK ID# <br /> I� , CUpgENTL AGENCY FACILITY IO# / <br /> APPROVED BY NAME PHONE#WITH ApEA CODE <br /> PEM MIT NUMBER <br /> PERMIT APPROVAL DATE PERMIT EXPIRgT10N DATE <br /> CHECK# PERMIT AMOUNT <br /> SU CHARGE AMT. FEE CODE <br /> RECEIPT BY: <br /> FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM'A' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />