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STATE OF CALIFORNIA* WATER RESOURCES CONTRO " ARD <br /> FORM 'B': UNDERGROUND <br /> ORAGE RM T APP!LiCATIQNIINFOR INFORMATION <br /> :NK PRO AM �� <br /> TAMC P <br /> TANK1 01 <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> 1 NEW PERMIT 3 RENEWAL PERMIT [e,05*'CHANGE OF INFORMATION E] 7 PERMANENTLY CLOSED TANK <br /> MARK ONLY 0 6 TEMPORARY TANK CLOSURE [:]8 TANK REMOVED JC <br /> ONE ITEM 02 INTERIM PERMIT 4 AMENDED PERMIT� N <br /> tZ � FARM TANK-YES� NO ❑ W <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: '[ <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY W <br /> B. MANUFACTURED BY'. mi2d e_r n a' YE <br /> A. OWNERS TANK ID# Ili <br /> G. YEAR INSTALLED 7 D. TANK CAPACITY M1N GALLONS, I <br /> 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. fl 1 MOTOR VEHICLE FUEL ❑ 2 ETROLEUM <br /> B. C. Q 1 UNLEADED E] 2 LEADED ❑ 3 DIESEL <br /> 3 CHEMICAL PR 4 OIL <br /> RODUCT ❑ 4 GASAHOL 0 5 JET FUEL 6 AVIATION GAS <br /> RO EMPTY E] 95 UNKNOWN 2 WASTE 1:17 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> 6 HAZARDOUS <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OFr f�Q f t Oil C.A.S.f1: I <br /> HAZARDOUS SUBSTANCE STORED&G.A.S.# �y (J[ ! <br /> I11. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF <br /> I' 1 ' DOU9LEWALLED E]3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM El2 SINGLE WALLED F-] 4 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEEL/IRON F-� 2 STAINLESS STEEL E] 3 FIBERGLASS 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC <br /> B.TANK El 5 CONCRETE 0 6 POLYVINYLCHLORIDE 7 ALUMINUM 8 100%METHANOL COMPATIBLE FRP <br /> MATERIAL �I 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> L❑� 1 RUBBER LINED 2 ALKYD LINING El 3 EPDXY LINING El 4 PHENOLIC LINING <br /> C. INTERIOR4 5 GLASS LINING fi UNLINED [:] 95 UNKNOWN <br /> LINING L� <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? El <br /> YES NO 99 OTHER <br /> D. CORROSION 1 POLYETHLENE WRAP 2 TAR OR ASPHALT 0 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 91 NONE D 95 UNKNOWN 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 PR SSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B. <br /> CONSTRUCTION A U 1 SINGLE WALLED OURLE WALLED 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 STAINLESSSTEEL A U 3 POLYVINYLCHLORIDE(PVC) A C' FIBERGLASS PIPE A U 91 NONE <br /> HANOL COMPATIBLE FRP <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%MET <br /> A U 9 GALVANIZED STEEL A U 95 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 /> P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS L P/S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> �f <br /> q'6 S 95 UNKNOWN S 99 OTHER <br /> P S 6 PREGISIONTESTING P S 7 PRESSURE7ESTING P 5 91 NONE <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 2. ESTIMATED QUANTITY OF �INERT <br /> K FILLED WITH <br /> ['�l ESTIMATED DATE LAST USED(MOIYR) SUBSTANCE REMAINING IN ATERIAL? YES NO <br /> GALLONS <br /> NA <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, I'S TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# /�j FACILITY ID# TANK ID# <br /> Li L_] V 1 � 131 <br /> APPROVED 8Y NAME PHONE K WITH AREA CODE <br /> CURRENT OCAL AGENCY FACILITY ID k <br /> PERMIT NUMBER PERMIT APPROVAL DA PERMIT EXPIRATION DATE <br /> CHECK k PERMIT AMOUNT SURCHARGE AMT. <br /> FEE CODE RECEIPT# BY: <br /> FORM B(6-29-8a) THIS FORM MUST BE ACCOMPANI dY A FACILITYISITE APPLICATION, FORM `A',UNLESS RRENT FORM`A' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />