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STATE OF OALIFORNO WATER RESOURCES CONTF*BOARD <br /> FORM 'B': UNDERGROUND STORAGE TANK PROGRAM <br /> TANK TANK PERMIT APPLICATION INFORMATION _ <br /> C PLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. p <br /> [FACILITY/SITE <br /> ;AR ONLY 1 NEW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ITEM 2 INTERIM PERMIT 4 AMENDED PERMITz r 6 TEMPORARY TANK CLOSURE �B TANK REMOVED NAME WHERE TANK IS INSTALLED: 9J'S C� <br /> FARM TANK-YES NO <br /> I. TANK DESCRIPTIONCOMPLETE ALL ITEM IF UNKNOWN—SO SPECIFY <br /> A. OWNERS TANK ID# 1 <br /> v B. MANUFACTURED BY: U <br /> C. YEAR INSTALLED <br /> D. TANK CAPACITY IN GALLONS: NOVO <br /> II. TANK CONTENTS IF(A,1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A <br /> A. 1 MOTOR VEHICLE FUEL PETROLEUM g, DO <br /> ❑ C. ❑ 1 UNLEADED •�il'•rrFeDED 3 DIESEL ' <br /> 3 CHEMICAL PRODUCT 4 OIL gODUCT 4 GASAHOL fG❑J 6 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS BO EMPTY � 95 UNKNOWN WgSTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&CA.S.# <br /> CA <br /> x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D <br /> A. TYPE OF ❑ I DOUBLEWALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN LI� _ <br /> SYSTEM �INGLEWALIED 0 4 SECONDARY CONTAINMENT 0 99 OTHER <br /> B. TANK EEUIRON 0 2 STAINLESSSTEEL 0 3 FIBERGLASS 4 STEEL CUD IN/FIBERGLASS ROME <br /> REINFORCE <br /> MATERIAL ❑5 CONCRETE 6 POLYVINYLCHLORIDE D 7 ALUMINUM B 100%METHANOL COMPATIBLE PAP RfefFM1T/SERVICES, <br /> 9 BRONZE 10 GALVANIZEDSTEEL" 95 UNKNOWN 99 OTHER <br /> C. INTERIOR 1RUBBER LINED 2ALKYDUNING 3EPDXY LINING 4 PHENOLIC LINING <br /> LINING ❑5 GLASS LINING '-)j� &NNLINED ❑95 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? DYES ONO D99 OTHER <br /> D.CORROSION ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT 0 3 VINYL WRAP 0 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION THODIC PROTECTION 91 NONE 0 95 UNKNOWN 0 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A.SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY <br /> A U OTHER <br /> S. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH U 5 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE <br /> C. MATERIAL A U 5 ALUMINUM A U B CONCRETE A U 7 STEELCLADW/FRP <br /> A U 9 GALVANIZED ST <br /> 95 UNKNOWN A U 8100%METHANOL COMPATIBLE FRP <br /> 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 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS <br /> P 8 6 PRECISION TESTING P 8 7 PRESSURETESFING P 8 91 NONE $ 95 UNKNOWN P $ gg OTHER <br /> V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF <br /> SUBSTANCE REMAININ11)) 3. WAS TANK FILLED WITH ' <br /> 'V GALLONS T TERIAL7 YES D NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED 851GN RE) <br /> LOCAL AGENCY <br /> COOL ANTYY## JURISDICTION# AGENCY# FACILITY ID R <br /> TANK ID# <br /> � � i <br /> CURRENT LOCAL AGENCY FACILITY ID p APPROVED BY NAME <br /> — � PHONEp WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PER IT EXPIRATION DATE <br /> CHECKp PERMIT AMOUNT SURCHARGE AMT. FEE CODE <br /> �RECEIPTBY: <br /> FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA HAS BEEN FILED W <br />