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STATE OF CALIFORNIA' WATER RESOURCES CONTROL ^OARD . <br /> FORM 'B': UNDE�6140UND STORAGE TANK PROMAM <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING FORMATION FOR EACH TANK. <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED <br /> FACILITYISITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO �► <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: cn <br /> C YEAR INSTALLED D. TANK CAPACITY IN GALLONS oa <br /> II. TANK TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A I MOTOR VEHICLE FUEL F-] 2 PETROLEUM B. C I UNLEADED 2 LEADED ❑ 3 DIESEL <br /> 3 CHEMICAL PRODUCT 4 OILPRODUCT 4 GASAHOL 0 5 JET FUEL F-] 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&C A.S.# C.A,S.W <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,K D <br /> A.TYPE OF L901iDOUBLE WALLED F] 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> $YSTEM ❑ 2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEEL/IRON 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK <br /> MATERIAL Il 5 CONCRETE 6 POLYVINYLCHLORIDE 7 ALUMINUM B 10C%METHANOL COMPATIBLE TRIP D 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> C. INTERIOR <br /> 1 RUBBER LINED F-] 2 ALKYD LINNG El 3 EPDXY LINING ❑ 4 PHENOLIC LINING <br /> I� <br /> LINING L-J 5 GLASS LINING 6 UNLINED 95 UNKNOWN <br /> ❑ IS LINING MATERIAL COMPATIBLE WITH IM METHANOLS � YES [:] NO � 99 OTHER <br /> D. CORROSION I POLYETHLENE WRAP 712 TAR OR ASPHALT 3 VINYL WRAP Q 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION �-9t"flaNE E] I 95 UNKNOWN l� 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U I SUCTION A t2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B. CONSTRUCTION A U I SINGLE WALLED AW 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 CHLORIDE(PVC) A61 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 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL 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 S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS 61 <br /> S 4 ELECTRONIC MONITOR P S 5 GROLJND WATER MONITORING WELLS <br /> P V <br /> 6 PRECISION TESTING P S 7 PRESSURE TESTING P $ 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? El 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# FACILITY ID# TANK ID# <br /> jU b 7 <br /> 7T <br /> CURRE T LOCAL AGENCY FACILITY ID# APPROVED BY NAME / / PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> ( CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: <br /> L <br /> FORM a(6-29-6a) THIS FORM MUST BE ACCOMPANIEtr FACILITY/S1TE APPLICATION, FORM `A',UNLESS A�"!i'FRENT FOAM'A' HAS BEEN FILED <br /> DATA PROCESSING-CL,."'` <br />