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STATE OF CALIFORN <br /> WATER RESOURCES CONTR OARD <br /> FORM `B': UND GROUND STORAGE TANK PR O PROMAM <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> �C9[IFO•N f <br /> MARK ONLY 0 I NEW PERMIT D 3 RENEWAL PERMIT <br /> ONE ITEM ED 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> 2 IT <br /> PERMIT 04 AMENDED PERMIT <br /> 6 TEMPORARY TANK CLOSURE ®-S TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED. 2' 1 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-$O SPECIFY FARM TANK-YES NO <br /> A. OWNERS TANK ID# Q <br /> B. MANUFACTURED BY: <br /> C. YEAR INSTALLED <br /> D. TANK CAPACITY IN GALLONS: <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> FNOT <br /> R VEHICLE FUEL 2 PETROLEUM B <br /> C. 1 UNLEADED 2 LEADED 3 DIESEL <br /> CAL PRODUCT D 4 OIL <br /> 1 PRODUCT �4 GASAHOL E]5 JET FUEL 6 AVIATION GAS <br /> DOUS BO EMPTY 0 95 UNKNOWN <br /> 2 WASTE 7 METHANOL gg OTHER(DESCRIBE IN ITEM D,BELOW) <br /> R VEHICLE FUEL,ENTER NAME OFSUBSTANCE STORED&C,A.S.# <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,S D CAS #: <br /> A. TYPE OF 0 I DOUBLE WALLED E]3 SINGLE WALLED WITH EXTERIOR LINER <br /> SYSTEM 0 2 SINGLE WALLED95 UNKNOWN <br /> 4 SECONDARY CONTAINMENT <br /> 99 OTHER <br /> MATERIAL �5 CONCRETE <br /> 0 1 STE€LPRON 0 2 STAINLESSSTEEL <br /> B. TANK 0 3 FIBERGLASS Q 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> 06 POLYVINYLCHLORIDE 0 7 ALUMINUM El 1D0%METHANOLCOMPATIBL€FRP <br /> 9 BRONZE 11 15 GALVANIZEDSTEEL Q 95 UNKNOWN D 99 OTHER <br /> C. INTERIOR ❑ I RUBBER LINED 2 ALKYD LINfNO Lj <br /> 3 EPO%YLINING 4 PHENOLICUNfNG <br /> LINING 5 GLASS LINING 0 6 UNLINED <br /> Q 18 LINING MATERIAL COMPATIBLE WITH IW%METHANOL? YES � NO �99 OTHER <br /> F-195 UNKNOWN <br /> D.CORROSION D I POLYETHLENE WRAP D 2 TAR OR ASPHALT <br /> PROTECTION ❑3 VINYL WRAP E]4 FEBERGLASS REINFORCED PLASTIC <br /> 5 CATHODIC PROTECTION D 91 NONE El 95 UNKNOWN [:]99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE:GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A.SYSTEM TYPE A u 1 SUCTION A U Z PRESSURE <br /> A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U gg OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> C.MATERIAL <br /> A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> A U 5 ALUMINUM <br /> A U 6 CONCRETE A U 7 STEEL CLAD W/FRP <br /> A U 6 16095 METHANOL COMPATIBLE FAP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN <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 S 1 VISUAL CHECK P 5 2 INVENTORY AECONCIUATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING <br /> P S 91 NONE P S 95 UNKNOWN <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE P s ss OTHER <br /> 1. ESTIMATED DATE LAST USED(MO/YR) <br /> 2. ESTIMATED QUANTITY OF <br /> SUBSTANCE REMAINING IN 3. WAS TANK FILLED WITH <br /> GALLONS INERT MATERIAL? DYES ONO <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) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# <br /> AGENCY# FACILITY ID# <br /> ED <br /> TANK Ip# <br /> CURRENT LOCAL AGENCY FACILITY 10# <br /> APPROVED BY NAME PHONE#WITH AREA CODE <br /> REKNIT NUMBER <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION HATE <br /> CHECK# PERMIT AMOUNT <br /> SURCHARGE AMT. FEE CODE <br /> RECEIPT# BY_ <br /> FORM B(6-29-$6) THIS FORM MUST BE ACCOMPANI A FACILITY/SITE APPLICATION, FORM `A',UNLESS A .1 ENT FORM`A' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />