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STATE OF CALIFORN WATER RESOURCES CONT BOARD <br /> �'�'iti awi}fir <br /> FORM 'B': UND GROUND STORAGE TANK PR RAM <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. o <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSE` NK <br /> ONE ITEM INTEfIIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE <br /> B TANK REMOVED /) <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES-NO <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: <br /> C. YEAR INSTALLED U4 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. C. 0 1 UNLEADED 02 LEADED FZKDIESEL Imo,) <br /> 3 CHEMICAL PRODUCT 0 4 OIL P-1/PRODUCT 0 4 GASAHOL ❑ 5 JET FUEL 0 6 AVIATION GAS <br /> ❑ 5 HAZARDOUS ❑ 80 EMPTY 0 95 UNKNOWN 2 WASTE 0 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.#: <br /> Al A <br /> x111. TANK CONSTRUCTION MARK ONE iTEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF n I UBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM �u�/2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEEL/IRON Ej 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD WIFIBEAGLASS REINFORCED PLASTIC <br /> B.MATERIAL. � 5 CONCRETE D 6 POLYVINYLCHLORIDE El 7 ALUMINUM 8 100%METHANOLCOMPATIBLEFRP <br /> 9 BRONZE El 10 GALVANIZED STEEL ❑95 UNKNOWN 99 OTHER <br /> C. INTERIOR 1 RUBBER LINED 0 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> LINING ❑5 GLASS LINING P�6UNLINED 95 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? Ej YES [::] NO 99 OTHER <br /> D.CORROSION F-1 I POLYETHLENE WRAP D 2 TAR OR ASPHALT 0 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION [::]5 CATHODIC PROTECTION E:] 91 NONE a ,KNKNOWN 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 99 OTHER <br /> B. CONSTRUCTION A 11 <br /> 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> A U i STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE{PVC} A U 4 FIBERGLASSPIPE <br /> C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W1FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A h) <br /> U 95 UNKNOWN A U 99 OTHER <br /> . 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 P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P rS_)6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 CTHFR <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED D 7E LAST USED(MO/YR) 2. ESTIMA E QUANTITY OF 3. WA TA aKllLL-ED WITHSUB MAINING IN I T IAL? E]YES � NO <br /> GALLONS <br /> THIS FO M NAS BEEN COMPLETED ANDER PENALTY OF RJURY,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 /> Lol o - ,� oE <br /> CURRENT LOCAL AGENCY F CILITY ID# APP D NAM PHONE#WITH AREA CODE <br /> PE IT NUMBER PE A PROVAL D PERMIT EXPIRATION DATE <br /> CHECK# PERMIT AMOUNT SURCH E FEE CODE RECEIPT# BY: <br /> FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIED A FACILITY/SITE APPLICATION, FOR M `A',UNLESS A CMENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />