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STATE OF CALIFORNIA WATER RESOURCES CONTROI ')ARD <br /> FORM `B': UNDERGROUND STORAGE TANK PROGRAM <br /> TANK 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;4-6rCHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED /S- <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: C%r, FARM TANK-YES❑ NO z <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY IC <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: u C <br /> C. YEAR INSTALLED g D. TANK CAPACITY IN GALLONS: <br /> w <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. Cg'l MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. k 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL <br /> ❑3 CHEMICAL PRODUCT ❑4 OIL Rl PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS <br /> ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED 8 CA.S.# CAS.#: <br /> All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,•D <br /> A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER 95 UNKNOWN <br /> SYSTEM 2r2 BNGLEWAUED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER <br /> 21 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> IL WTERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP <br /> ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER <br /> C.INTERIOR j ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC UNING <br /> I LINING ❑5 GLASS LINING �6 UNLINED ❑95 UNKNOWN <br /> ❑IS LINING MATERIAL COMPATIBLE WITH 100%METKWL? ❑YES ❑ NO ❑ 99 OTHER <br /> D. CORROSION ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT ❑ 3 VINYLWRAP ❑ 4 RBERGLASS 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 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEA TRENCH A(095 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE <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 AD95 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 /> 1 P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS <br /> V S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 6 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 EIU.ED WITH <br /> GALLONS <br /> SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES [:j NO <br /> I <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID N <br /> CURRENT, `/LOCAL AGENCY FACILITY IDN APPROVED BY PHONE N WITH AREA CODE 0 L5 <br /> PERMIT NUMBER PERMIT APPROVAKDATE 'PERMIT EKP 10 TE <br /> CHECK N PERMIT AMOUNT - SURCHARGE AMT. FEE CODE -RECEIPT N BY: <br /> FORM 8(3-7-88) THIS FORM MUST BE ACDOWANIO BY A FACIUTY/SIIE APPLICATION, FORM`A',UNLESS A ENT FORMA' HAS BEEN FILED <br /> L - _ _ DATA PROCESSING COPY <br />