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STATE OF CALIFOR <br /> FORM B : WATER RESOURCES CON <br /> UN RGROUND STORAGE TANK PROGRAIVMD J� <br /> TANK TANK PERMIT APPLICATION INFORMATION q ' <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR <br /> MARK ONLY 0 2 INTERIM PERMIT 1NEW PERMIT ❑ - EACH TANK. <br /> ONE ITEMEl 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION <br /> FACILITY/SITE NAME WHERE TgNK IS INSTALLEoa <br /> RMANENTLY CLOSED TANK <br /> D: <br /> A. OWNERS ❑6 TEMPORARY TANK CLOSURE <br /> 8 TANK REMOVED <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS IF UNKNOWN_` s Sf <br /> �1 FARM TANK-YES NO <br /> TANK ID q SO SPECIFY <br /> C. YEAR INSTALLED / / _0co B. MANUFACTURED By; ! o <br /> TAN <br /> 11. TANK CONTENTS (A.1) <br /> D. K CAPACITY GALLONS: <br /> IN d3 A.1),IS MARKED,COMPLETE ITEM C.IF(AgU <br /> 7),IS NOT MARKED,COMPLETE ITEM D. <br /> A. IF(1 MOTOR VEHICLE FUEL 2 PETROLEUM <br /> 3 CHEMICAL PRODUCT 4 OIL B O C' ❑ 1 UNLEADED ¢ EADED 3 DIESEL N <br /> 05 HAZARDOUS �BD EMPTY g5 UNKNOWN 1 PRODUCT 4 GASAHOL y <br /> 5 JET FUEL fi AVIATION GAS <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME 0 2 WASTE ❑7 METHANOL gg OTHER(DESCRIBE IN ITEM D,BELOW) <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# /a _ <br /> All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D CAS # .3 <br /> A TYPE OF ❑ I DOUBLEWALLEp <br /> SYSTEM ❑3 SINGLE WALLED WITH EXTERIOR LINER <br /> 2 SINGLE WALLED ED4 SECONDARYCONTAWMENi 95 UNKNOWN <br /> 1 STEEUIRON EDW OTHER <br /> B.TANK ) ❑2 STAINLESS STEEL 3 98ERGLASS <br /> E]MATER ❑5 CONCRETE 6 POLYVINYLCHLORIDE GALVANIZED STEEL 4 STEEL CLAD W/FIBEgGU15S REINFORCED PLASTIC <br /> 9 BRONZE 7 ALU M ❑B 1 OR METHANOL COMPATIBLE FRP <br /> 10 / UNKNOWN I � <br /> 1:11 RUBBER NEO )-'-JJ 99 OTHER <br /> C.INTERIO 2 ALKYD LINING 3 EP0X1'LINING <br /> LININ /� ❑5 GLASS UNf�{R�7 /r :'('�6 UNLINED ❑4 PHENO NTNG <br /> IS LINING MATERIAL COMPATIBLEWITHIGOS METHANOL ElUNKNOWN <br /> D. CORROSI ( 1 POLYETHIENE WRAP / 0 YES NO ❑99 OTHER <br /> PROTECT ❑2 TARORASPHALT E]3 VINYLWq <br /> E]5 CATHODIC PROTECTION 0 91 NONE ❑4 FIBERGLASS REINFORCED PLASTIC <br /> KNOWN El N OTHER <br /> IV. PIPING INFORMATION CIRCLE A IFABOVE GROUND, U IF UNDERGROUND, <br /> BOTH IF APPLICABLE <br /> A SYSTEM TYPE A U 1 suoTIDN <br /> B.CONSTRUCTIV A U 1 SINGLE WALLED A U 2 PRESSURE <br /> A U 3 GRAVITY A U 99 OTHER <br /> A U 2 DOUBLE WALLED A U 3 LINED TRENCH <br /> h�� ' A U 1 STEEL/IRON A U 2 STAINLESS STEEL A A U 95 UNKNOWN <br /> C. MATERIAL �./ A U 5 ALUMINUM U 3 <br /> A U POLYVINYLCHLORIDE PVC A U 99 OTHER <br /> 6 CONCRETEA U 7 S ( ) A U 4 FIBERGLASS PIPE <br /> OTHER <br /> A U 99 OTHER <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN ADW/FRP A U 8100%METHANOL COMPATIBLE FRP <br /> V. L DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM <br /> 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S MUST BE CIRCLED. <br /> 4 ELECTgONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS <br /> P 6 PRECISION TESTING P S ]PRESSURE TESTING P B 91 NONE <br /> P/S 95 UNKNOWN P'tJ5 99 OTHER- <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MO/YR) <br /> 2. ESTIMATED OUANTIry OF <br /> SUBSTANCE REMAINING IN 3. WAS TANK FILLED WITH <br /> GALLONS INERT MATERIAL? YES <br /> rvisFoayNgSBEENNO <br /> ,COMPLETEO UNDER PENALTY OF PER AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> :::::::APPLICANT'S NAME(PAINTED 851GNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> OUN7Y# JURISDICTION# <br /> AGENCY# .Z' FACILITY ID# <br /> TANK ID//# <br /> C ENT LOCAL AGENCY FACILITY IDk <br /> tp c) APP VED BY NAME <br /> 9 Gp PHONE p WITH AREA CODE <br /> RMIT NUMBER �3 0 0 <br /> P RL�IT APPROVAL DATE PEP IT EXPIRATI DATE <br /> CHECK# PERMITAMOUNT <br /> SURCHARGE AMT. FEE CODE <br /> RECEIPT# By. <br /> FORM B(3-7-88) THIS FORM MUST BE ACCOMPANI tlY A FACILIT'F/SITE APPLICATION, FORM `A',UNLESS RENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />