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STATE OF CALIFORNI WATER RESOURCES CONTRO`OARD <br /> FORM `B': <br /> UNDERGROUND STORAGE TANK PROGRAM m" <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. o <br /> MARK ONLY ❑ 1 NEW PERMIT F_� 3 RENEWALPERMIT 0 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM 2INTERIM PERMIT 4AMENDED PERMIT TANK REMOVED <br /> 6TEMPORARY TANK CLOSURE 6 <br /> W <br /> i , /� FARM TANK-YES❑ NO CA) <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: V .jam <br /> I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY �� <br /> DO <br /> A. OWNERS TANK ID# B. MANUFACTUEEDBY: <br /> 2- <br /> D. TANK CAPACALLONS: <br /> WEI <br /> C.YEAR INSTALLED <br /> II. TANK C2L&ENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. <br /> B C. ❑ 1 UNLEADED LEADED 3 DIESEL 1�RRODUCTA. E57MOTOR VEHICLE FUEL 0 2 PETROLEUM <br /> 3 CHEMICAL PRODUCT �4 OIL <br /> 1 PRODUCT ❑4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 95 UNKNOWN 2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> Fj 5 HAZARDOUS 80 EMPTY <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# <br /> III.rLTYPE <br /> NK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C, D <br /> OF � I �LEWALLED ❑3 SINGLE WALLEDWITH EX ERIOR LINER 95 UNKNOWN <br /> STEM 11—�L`fSINGLEWALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> EEL/IRON 2 STAINLESS STEEL 0 3 FIBERGLASS 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC <br /> B.TANK F7 5 CONCRETE 6 POLYVINYLCHLORIDE F-I 7 ALUMINUM B 100%METHANOL COMPATIBLE FRP <br /> MATERIAL ❑ 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED 2 AIRY NO 3 EPDXY LINING 4 PHENOUC LINING <br /> C. INTERIOR 5 GUSS UNING � <br /> MUNED 95 U KNOWN A <br /> LINING R <br /> IS LINING MATERIAL COMPATIBLE WITH 10D%METHANOL? 0YES ONO 99 OTHER nA <br /> D.CORROSION ❑ I POLYETHLENE WRAP �2 T OR ASPHALT ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 1 NONE ❑95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> S.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE U 95 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 A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A 9 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 /> Ovi. P S 1VISUALCHECK P S 2 INVENTORY RECONCILIATION P 8 3VADOSEWELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURETESTING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLED WITH <br /> 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF INERT MATERIAL? YES NO <br /> . I SUBSTANCE REMAINING IN GALLONS <br /> THIS FORM HAS BEE COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> DATE <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> CJI / FACILITY ID k TANK ID# <br /> COUNTY# JURISDICTION� AGE h <br /> CURRENT LOCAL AGENCY FACILITY ID k <br /> APPROVED BY NAM PHONE k WITH <br /> AREA CODE <br /> 4mM !: <br /> PERMIT NUMBER PERMIT APPROVAL DATE P RMI EXPIRATION ATE <br /> ` , I CHECKk PERMIT AMOUNT SURCHARGE AMT, FEE CODE <br /> RECEIP BY: <br /> �J�/ FORM B(6-29-86) THIS FORM MUST BE ACCOMPANIE Y A FACILITYDATAAPPLICATION, <br /> FGORM A',UNLESS A L, RENT FORMA' HAS BEEN FILED <br />