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46F.v+i.A "r <br /> STATE OF CALIFORN WATER RESOURCES CONTR OARD <br /> FORM `B': UND GROUND STORAGE TANK PR RAMS„ <br /> �[ <br /> TANK PERMIT APPLICATION INFORMATION <br /> TANK <br /> 1 AN K C PLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY 1 NEW PERMIT <br /> ­ <br /> MARK <br /> RENEWAL PERMIT 5 CHANGE OF INFORMATION 07 PERMANENTLY CLOSED TANK <br /> ONE ITEM � 2 INTERIM PERMIT � 4 AMENDED PERMIT �6 TEMPORARY TANK CLOSURE �B TANK REMOVED <br /> FARM TANK-YES� NO <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: � I ��� (�• T l lx' �Q <br /> I. TANK DESCRIPTION ECOMPLETE ALL ITEMS-IF UNKNOWN–SO SPECIFY mss, <br /> B. MANUFACTURED BY: br. >$ Ch'!�'`r► ' <br /> A. OWNERS TANEID# ]i DTANK CAPACITY IN GALLONS: $'C. YEAR INSTALLtyl <br /> II. TANK NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM 2 LEADED �3 DIESEL <br /> B. <br /> [M� <br /> 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM 4 GASAHOI- 0 5 JET FUEL 0 6 AVIATION GAS <br /> 3 CHEMICAL PRODUCT 0 4 OIL 1 PRODUCT <br /> 5 HAZARDOUS 0 <br /> B0 EMPTY 95 UNKNOWN 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> . IF NOT MQTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# <br /> Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,8,C,A D <br /> 1 DOUBLE WALLED F-] 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN <br /> A.TYPE OF 4 SECONDARY CONTAINMENT 99 OTHER <br /> SYSTEM 0 2 SINGLE WALLED <br /> I STEEL11RON El 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK El 5 CONCRETE F-1 6 POLYVIWLCHLORIDE F-1 7 ALUMINUM ❑ 6 100%METHANOL COMPAT19LE FRP <br /> MATERIAL F–)9 BRONZE 0 10 GALVANIZED STEEL 95 UNKNOWN 0 99 OTHER <br /> 1 BBER LINED 2 ALKYD LINING 3 EPDXY LINING 0 4 PHENOLIC LINING <br /> C. INTERIOR E] 95 UNKNOWN <br /> 5 GLASS LINING Q 6 UNLINED <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? 0 YES D NO D 990 <br /> LINING PER <br /> IBEflGLASS REINFORC PLASTIC <br /> D.CORROSION ❑ I POLYETHLENEWRAP 2 TARORASPHALT 3 VINYL <br /> El <br /> PROTECTION � 5 CATHODIC PROTECTION Q 91 NONE El <br /> 95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABO GRCUND, U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A �Ul 1 NONE A U 95 UNKNOWN A U 99 OTHER <br /> $. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U LINED TRENCH A 1 NONE A U 95 UNKNOWN A U 99 OTHER <br /> 4 FIBERGLASS PIPE A U 91 NONE <br /> A U 1 STEELPRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE{PVC) A U 6 100%METHANOL COMPATIBLE ERP <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP <br /> A U 9 GALVANIZED STEEL A U 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 /> LPS <br /> 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION p S 3 VADOSE WELLS PP 5 4 E95 LECTRONIC MONITOR NOWN P 5 55�GROUNDWATER RMONITORING WELLS <br /> 6 PRECISION TESTING P S 7 PRESSURE BET <br /> P S 91 NONE <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE F3�WAS TANK FILLED WITH <br /> IMATED QUANTITY G IINERT MATERIAL? DYES ONO' <br /> SUBSTANCE REMAINING IN GALLONS <br /> THIS FORM HAS BEEN CCiMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, <br /> 1S TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRYNTE'&SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# <br /> FACILITY ID# TANK ID# <br /> ffC f— LO-Lo-�J <br /> CURRENT LOCAL AGENCY FACILITY IDM <br /> APPROVED BY NAME PHONE#WITH AREA CODE <br /> h <br /> PERMIT APPROVAL DATE PERMIT EXPIRAT ON DATE <br /> PERMIT NUMBER <br /> RECEIPT BY: <br /> CHECK# PERMIT AMOUNT URCHARGE AMT. <br /> FEE CODE M <br /> FORM B(6-29-86) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SDA PROCESS NOGCOPY <br /> UNLESS A CURRENT FORM`A° HAS BEEN FILED <br />