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STATE OF CAUFIA <br /> WATER RESOURCES C&RpL BOARD <br /> FORM 'B': DERGROUNO STORAGE TANK PROGRAM Go <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY 1 NEW PERMIT 3RENEWAL PERMITE�Kez <br /> - <br /> 2 INTERIM PEflM1 <br /> ONE ITEM CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> T 4 AMENDED PERMIT <br /> 6 TEMPORARY TANK CLOSURE �8 TANK REMOVED <br /> FACILITY/317E NAME WHERE TANK IS INSTALLED: <br /> e. Lo <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 0 FARM TANK-YES NO J1 <br /> A. OWNERS TANK ID K N <br /> C. YEAR INSTALLED <br /> B. MANUFACTURED BY: <br /> D. TANK CAPACITY IN GALLONS: � <br /> 11. TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A,1),IS NOT MARRED, <br /> A. 1 MOTOR VEHICLE FUEL 2 PETROLEUM COMPLETE ITEM DB <br /> C. ❑ <br /> 3 CHEMICAL PRODUCT �q OIL 1 UNLEADED 2 LEADED <br /> 3 DIESEL <br /> 5 HAZARDOUS 80 EMPTY 95 PRODUCT 4 GASAHOL El 5 JE FUEL 6 AVIATION GAS <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF❑ UNKNOWN 2 WASTE 7 METHANOL 0 99 OTHER(DESCRIBE IN ITEM D.BELOW) <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.q A 4_1A <br /> Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,&D C.A.S.X: <br /> A. TYPE OF ❑ 1 DOUBLEWALLED 3 SINGLE WALLED WITH EKTERIOR LINER <br /> SYSTEM E!�lSINGLE WALLED 4 SECONDARY CONTAINMENT ❑95 UNKNOWN <br /> 99 OTHER <br /> S. TANK E] I STEEUIRON E]2 STAINLESS STEEL 3 FIBERGLASS <br /> MATERIAL ❑5 CONCRETE 0 6 POLYVINYLCHLORIDE 7 ALUMINUM ED ED 4 STEEL CLADNOL COMPATIBGLASSLE <br /> REINFORCED PLASTIC <br /> 9 BRONZE El 10 GALVANIZEDSTEELUNKNOWN 8 10096 METHANOL COMPATIBLE FRP <br /> N OTHER <br /> C. INTERIOR ❑ 1 RUBBER UNED 2 ALKYD LINING 3 EPDXY UNING 4 PHENOLICUNING <br /> LINING ❑5 GLASS LINING UNLINED <br /> IS LINING MATERIAL COMPATIBLE WITH I00%METHANOL? YES ❑9999 UNKNOWN <br /> ❑ �NO � OTHER <br /> D.CORROSION ❑1 POLYETHLENEWRAP ED 2 TAR ORASPHALT 3 VINYL <br /> PROTECTION 5 CATHODIC PROTECTION WRAP <br /> 97 NONE ❑4 FIBERGLASS REINFORCED PLASTIC <br /> 95 UNKNOWN 99 OTHER <br /> IV. PIPING INFOt!!!!ZjoN CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE <br /> B. CONSTRUCTION A 1 SINGLE WALLEDA U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> A U 2 DOUBLE WALLED A U 3 LINED TgENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> A U i STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYLCHLORIDE PVC <br /> C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE ( I A U 4 FIBERGLASS PIPE A U 91 NONE <br /> A U 9 GALVANIZED STEEL A �g5 UNKNOWN A U 7 STEEL CLAD W/FRp A U 8100%METHANOL COMPATIBLE FRP <br /> VVVV 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 i k 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS <br /> P 8 6 PRECISION TESTING 8 7 PRESSURE TESTING P S 91 NONE <br />�- P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED D E LAST USED(MO/YR) <br /> 2.ESTIM ED OUANTITV OF <br /> SU STN REMAINING IN 3. WAS TA FILLED WITH <br /> GALLONS INERT RIAL? DYES E] NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLE GE,IS TRUEAND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COU� JURISCm AGENCY X <br /> FACILITY ID# TANK ID 8 <br /> b d d0CURRENT LOCAL LOCAL AGENCY FACILITY ID X <br /> /rr APPVOVEDByN E PHONE X WITH AREA CODE <br /> ! <br /> PERMIT NUMBERAw- d <br /> PERMIT APPROVAL DATE PERM] EXPIRATION DATE <br /> CHECKM PERMIT AMOUNT <br /> SURCHARGE AMT. FEE CODE <br /> RECEIPTM BY: <br /> PDRM B(&-29-06) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A'' <br /> ORM 'A',UNLESS A CURRENT FORMA' HAS BE <br /> DATA PROCESSING COPY EN FILED <br />