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STATE OF CALIFORNItS WATER RESOURCES CONTRONK MPARD <br /> FORM `B': UNDTANK PERMIT APPLICATION ND STORAGE IL FORMATION <br /> TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING I FORMATION FOR EACH TANK. <br /> F-11 N ERMIT F-13 RENEWALPERMIT CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK <br /> MARK ONLY <br /> ONE ITE ,�, 2/INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK RE Eq 02- <br /> ARM TANK-YES NO Lys z <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED L I <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> B. MANUFACTURED BY' <br /> A. OWNERS TANK IDS a�SS- QVV 6 <br /> C.YEAR INSTALLED L D. TANK CAPACITY IN GALLONS' QUC' <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> N <br /> C. UNLEADED ❑2 LEADED ❑3 DIESEL <br /> -13 CHEMICAL PRODUCT 4 OIL <br /> A. MOTOR VEHICLE FUEL 2 PETROLEUM PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS <br /> ❑ ❑ 2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN IT/EM D,BELOW) <br /> 5 HAZARDOUS ❑80 EMPTY ❑ 95 UNKNOWN <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME�a / C.A.S.g /3 N <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.H <br /> Kill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A TYPE OFO ❑ 1 DOUBLEWALLEO 3 SINGLEWALLED WITH EXTEflIORU. 5 UNKNOWN <br /> SYSTEM l74 ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER <br /> ❑ 1 STEELIIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CIAO W/RBERGLSS REINFORCED PLASTIC <br /> B.TANK Ae ❑ <br /> /� 5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP <br /> MATERI `"/ ❑9 BRONZE ❑10 GALVANIZED STEEL UNKNOWN El W OTHER <br /> ❑ 1 RUBBERLINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑ 4 PHENOLICUNING <br /> C. INTERIOR ❑5 GLASS LINING ❑6 UNLINED [pl9LUNKNOWN <br /> LINING <br /> ❑ IS LINING MATERIAL COMPATIBLEW1TH 100%METHANOL O YES 0 ❑99 OTHER <br /> D. CORROSIO ❑ I POLYUHLENEWRAP ❑2TAR OR ASPHALT ❑3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE re95 UNKNOWN ❑ 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> SYSTEM TYPE / A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> A A SINGLE WALLIED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> B.CONSTSYSTEMIUCTI <br /> /yam A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 100%METHANFIBERGLASS L <br /> C. MATERIAL/qi 1 A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP <br /> /L// A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER <br /> �V. LE K DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS <br /> p 6 PRECISION TESTING S 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> �.2 ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> 1. ESTIMATED DATE LAST USED(MO/YR) SUBSTANCE REMAINING IN NERT MATERIAL? ❑YES E] NO <br /> GALLONS L� <br /> THIS FORM HAS BEEN COMPL ED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> CY X <br /> COUNTY# JURISDICTION# AGEN <br /> FACILITY ID N n;7 TANK ID X <br /> a a a- S 0 0 <br /> PHONE t WITH AREA CODE <br /> CU NT LOCAL AGENCY FACILITY IDX <br /> ppP VED BY NA /� <br /> MIT APPROVA DATE PERMIT EXPIRATION DATE <br /> PERMIT NUMBER <br /> REC <br /> CNECKX PERMIT AMOUNT SURCHARGE <br /> GE T. FEE CODE EIPT0 BY: <br /> FORM B(3-7-88) THIS FORM MUST BE ACCOMPANI . A FACILITY/SITE APPLICATION, FORM `A',UNLESS RENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />