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STATE OF CALIFORNI F WATER RESOURCES CONTRO' BOARD <br /> FORM `B': UNDE7iGROUND STORAGE TANK PROGRAM ' <br /> YANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWIN NFORMA710N FOR EACH TANK. <br /> MARK ONLY ❑ 1 NEW PERMIT 0 3 RENEWAL PERMIT z <br /> ONE ITEM 5 CHANGE TA OF INFORMATION 7 PERMANENTLY CLOSED TANK (f� <br /> E 2 INTERIM PERMIT 0 4 AMENDED PERMIT <br /> 6 TEMPORARY TANK CLOSURE B TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN- FARM TANK-YES NO <br /> /r SO SPECIFY w <br /> A. OWNERS TANK ID# <br /> B. MANUFACTURED BY: U� Cn <br /> C. YEAR INSTALLED <br /> D. TANK CAPACITY IN GALLONS' <br /> 11. 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 2 PETROLEUM B. O- ❑ 1 UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT 0 4 OIL 1 PRODUCT 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS 0 80 EMPTY5 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 A C.A.S.# <br /> C.A.S.#: <br /> 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D <br /> I DOUBLE WALLED <br /> A. TYPE OF 351NGlE WALLED WITH EXTERIOR LINERUNKNOWN <br /> SYSTEM F�2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> B.TANK ❑I STEELPRON ❑2 STAINLESS STEEL D 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCEDPLASTIC <br /> MATERIAL 5 CONCRETE ❑6 POLYVINYL CHLORIDE 7 ALUMINUM 6100%METHANOL COMPATIBLE FRP <br /> 9 BRONZE 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER <br /> C. INTERIOR ❑ 1 RUBBER LINED 2ALKYD UNING 3 EPDXY LINING ❑4 PHENOLIC LINING <br /> LINING ❑5 GLASS LINING 6 UNLINEDKNOWN <br /> ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER <br /> D. CORROSION ❑ 1 POLYETHLENEWRAP 2TAR OR ASPHALT ❑�3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 91 NONE CJ °"UNKNOWN D 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 Aff295 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 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEELCLAOW/FRP A U 810M METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL 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 1VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3VADOSE WELLS S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S S9 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1, ESTIMATED DATE LAST USED(MO/YP) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? DYES ONO <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 8 TANK IO# <br /> L51 1911 1 141av <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK N PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT N BY: <br /> FORM a(6-29-66) THIS FORM MUST BE ACCOMPANIED- P A FACILITY/SITE APPLICATION, FORM `A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />