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STATE OF CALIFORNP WATER RESOURCES CONTRr ARD <br /> K PRAM <br /> �• ND�ROUND STORAGE TAN , <br /> I FORM B . U <br /> NK TANK PERMIT APPLICATION INFORMATION . <br /> TA COMPLETE A SEPARATE FORM WITH THE FOLLOWING! FORMATION FOR EACH TANK. <br /> MARK ONLY ❑ i NEW PERMIT 3 RENEWAL PERMIT <br /> 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM F-1 2 INTERIM PERMIT D 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK FARM TANK REMOVED <br /> NO <br /> �WIHEREa <br /> FACILITYl51TE NAMETANK IS INSTALLED: <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY <br /> B. MANUFACTURED BY: <br /> A. OWNERS TANK ID# 110 <br /> i C. YEAR INSTALLED 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 /> ! A. 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. 1 UNLEADED 2 LEADED 3 DIESEL <br /> E]3 CHEMICAL PRODUCT OIL 1 PRODUCT ❑4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS 80 EMPTY 95 UNKNOWN F�4ASTE 7 METHANOL [:] 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME QF � � � Q C.A.S.#: <br /> V S <br /> HAZARDOUS SUBSTANCE STORED&G.A.S.N -C <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF ❑1 0 UBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED Q 4 SECONDARY CONTAINMENT 99 OTHER <br /> STEEL1kRON 2 STAINLESSSTEEL 3 FIBERGLASS 4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC <br /> + B.TANK 5 CONCRETE F-1 6 POLYVINYLCHLORIDE [:] 7 ALUMINUM E]8 100%METHANOL COMPATIBLE FRP <br /> MATERIAL ❑9 BRONZE 10 GALVANIZED STEEL ❑95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED ❑2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC <br /> LINING <br /> i C.INTERIOR 5 GLASS LINING E-16 UNLINED <br /> LINING <br /> t IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES 0 NO 99 OTHER <br /> D.CORROSION ❑ 1 POLYETHLENE WRAP F_�2 TAR OA ASPHALT F-1 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 0 5 CATHODIC PROTECTION E] 91 NONE 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 2 PRESSURE A U 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 WALLED A U 3 LINED TRENCH 'A U 91 NONE A U 5 UNKNOWN A U 99 OTHER <br /> . A U 1 STEEL/IRON A U 2 STAINLESS STEEL 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 WlFRP A U 8 100%METHANOL COMPATIBLE FRP <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 = r, S 2 INVENTORY HECONGILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS <br /> ll <br /> P(D 6 PRECISION TESTING`vP 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) _72. ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN INERT MATERIAL? YES E] NO <br /> pALLONB <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO WLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE - <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> 0 10 L I q I k <br /> D� Q <br /> [CHECK <br /> URRENT LOC AG NCY FACILITY ID N APPRO ED BY AME 414, PHONE N WITH AREA CODE <br /> /vy , /�. <br /> 19 <br /> RMIT NUMBER PERMIT APPROVAL DA PERMIT EXPIRATION DATE <br /> N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: <br /> 'a <br /> S <br /> FORM B(6-29-86) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'N.UNLESS A IRRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />