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STATE OF CALIFORNIJB WATER RESOURCES CONTRO OARD ,s•'`Ndi' <br /> FORM `B': UNDE ROUND STORAGE TANK PROAM <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> 10 <br /> MARK ONLY CTI-_'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 /> W <br /> FACILITY/SITE NAIVE WHERE TANK IS INSTALLED: I'm in, t'x � FARM TANK-YES❑ NO �3 <br /> L TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY .A• <br /> A. OWNERS TANK ID 4 b Z B. MANUFACTURED BY: <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: L !� <br /> II. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. El MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED DIESEL <br /> ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET'FUEL ❑ 6 AVIATION GAS <br /> ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTF ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM O,BELOW) <br /> I� D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.q &1A C.A.S.N: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> A.TYPE OF ❑ 1 DOUBLE WALLED �3 SINGLE W ❑ <br /> SYSTEM P P SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER <br /> 21,'STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM F-] 6 100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER <br /> 1 RUBBER LINED 2_ D LINING F-] 3 EPDXY LINING 4 PHENOLIC LINING <br /> C. INTERIOR <br /> LIMING 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN <br /> ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑ YES ❑ NO ❑ 99 OTHER <br /> D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT 49�SLINKNOWN <br /> 3 WL' <br /> ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION [:] 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A.SYSTEM TYPE A Ue SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B. CONSTRUCTION A(U;)l SINGLE WALLED 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 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE <br /> C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A 0 <br /> 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 1 VISUAL CHECK ( P1 S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELLS <br /> P 6 PRECISION TESTING P S 7 PRESSURETESTING P 5 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VL INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMA ED QUANTITY OF 3. WA <br /> GALLONS ANK FILLED WITH <br /> J SUB T NCE REMAINING IN I" <br /> T MATERIAL? E]YES ONO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENA:4 OF PERJURY,AND TO THE BEST OF MY KNO All EDGE, IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COE�l <br /> NTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> � p YE <br /> CURB T LOCAL AGENCYCILITY IDM APPRO D - NAME,, n I PHONE M WITH AREA CODE <br /> jT <br /> PERMIT NUMBER PERMI P OV L PEBMIT/Ef EXPIRATION DATE <br /> CHECK M PERMIT AMOUNT SURCHAR 'E A T. FEE CODE RECEIPT M BY: <br /> FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM `A',UNLESS A ENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />