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STATE OF CALIFORNI/0 WATER RESOURCESCONTROJARD "• <br /> FORM `B': UNDERGROUND STORAGE TANK PRO AM �o <br /> TANK TANK PERMIT APPLICATION INFORMATION �o Z <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> IO <br /> MARK ONLY ❑ 1 NEW PERMIT F-� 3 RENEWALPERMIT Fj21rcRANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM F-1 2 INTERIM PERMIT F-14 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: ed FARM TANK-YES[:] NO <br /> CA <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY VI <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 3 5-0 <br /> 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,CqMPLETE ITEM D. <br /> A. MOTOR VEHICLE FUEL 2 PETROLEUM B. C. 1 UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT F-1 4 OIL 41PRODUCT ❑4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS E] 80 EMPTY [:] 95 UNKNOWN 2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. 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,&D <br /> A.TYPE OF ❑ I DOUBLEWAL D F-] 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 0 2 SINGLE WALLED F-� 4 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEEL/IRON2STAINLESS STEEL � 3FIBERGLASS 4MEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> S. TANK 5 CONORETE fi POLYVINYLCHLORIDE 7 ALUMINUM 8180%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> BER LINED ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> C. INTERIOR:::SS LINING �6 LINED 95 UNKNOWN <br /> LINING <br /> ING MATERIAL COMPATIBLE WITH I METHANOL? YES NO 99 OTHER <br /> D. CORROSION ❑ I POLYETHLENEWRAP 2 TARORA HALT ❑3 VINYL WRAP E]4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROU . U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURL A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WAL�D A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESS STE A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR CONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS`.P 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P` S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? YES [�] NO <br /> THIS FORM HAS BEEN COMPLETED 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 /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> CURRENT LOCAL AGENCY F CILITY IDN APPROVED BY NAME PHONE k WITH AREA CODE <br /> ` PERMIT NUMBER PERMIT APPROVAL DATE PERM EXPIRATION DATE <br /> I r <br /> CHECKN PERMITAMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY: <br /> I ilia <br /> FORMB(6-29-68) THIS FORM MUST BE ACCOMPANIE AFACIUTY/SITE APPLICATION, FORM 'A',UNLESS ACURRENT FORMA' HASBEENFILED <br /> DATA PROCESSING COPY __�_ <br />