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STATE OF CALIFORNIS WATER RESOURCES CONTR*OARD <br /> FORM 'B': LAND GROUND STORAGE TANK PROGRAM <br /> TANK TANK PERMI APPLICATION INFORMATION <br /> COMPLETE A SEPARATE F WITH THE FOLLOWING INFORMATION FOR EACH TANK. N 0 <br /> MARK ONLY ❑1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY C K <br /> ONE ITEM 2 INTERIM PERMIT 1:34 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVEDto, <br /> o, Ca <br /> 6 / OEA TANK-YES❑ NO W <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: V -4 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: 6 <br /> D. TANK CAPACITY IN GALLONS: .'q' Q-- Q <br /> C. YEAR INSTALLED <br /> II. TANK NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. <br /> B C. ❑ 1 UNLEADED 2 LEADED 3 DIESEL <br /> A. 1 MOTOR VEHICLE FUEL 2 PETROLEUM <br /> 3 CHEMICAL PRODUCT � 4 OIL <br /> 1 PRODUCT ❑4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS BO EMPTY D 95 UNKNOWN 2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,h D <br /> A.TYPE OF ❑ 1 UBLEWALLED E]3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED 4 SECONDARY CONTAINMENT <br /> 99 OTHER <br /> I STEELIIRON E]2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CIAO W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK 5 CONCRETE 6 POLYVINYLCHLORIDE 7 ALUMINUM 8 METHANOL COMPATIBLE FRP <br /> MATERIAL ❑ 9 BRONZE 10 GALVANIZED STEEL Ej 95 UNKNOWN Lg 99 OTHER t2 <br /> t2 <br /> C. INTERIOR 1 RUBBER LINED 2 ALKYD LINING F_�3 EPDXY LINING D 95PHENOLI UNING <br /> WN <br /> LINING ❑5 GLASS UNING 6 UNLINED <br /> IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? YES O NO OTHER <br /> D. CORROSION ❑ 1 POLYETHLENE WRAP 2TAR OR ASPHALT IWL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN 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 A U 95 UNKNOWN A U 99 OTHER <br /> B.CONSTRUCTION A U 1 SINGLEWALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE Al 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 Ap,6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A 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 /> Q7 8 1VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLED WITH <br /> 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF <br /> SUBSTANCE REMAINING IN INERT MATERIAL, <br /> YES DNO <br /> GALLONS <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> DATE <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> FACILITY ID# TANK ID# 7 <br /> COUNTY# JURISDICTION# AGE / <br /> Ob � 20 Do a <br /> APPROVED BY NAME PHONE#WITH AREA CODE <br /> CURRENT LOCAL AGENCYFACILITY / ly� <br /> PERMIT NUMBER �M[ S PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE <br /> RECEIPT# BY: <br /> FORM B(6-29-B6) THIS FORM MUST BE ACCOMPANIED BY A FACILITYPPROCION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> DATA / <br />