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STATE OF CALIFORNI WATER RESOURCES CONTRO ARD <br /> FORM `B': UNDE ROUND STORAGE TANK PRO AM Y <br /> TANK TANK PERMIT APPLICATION INFORMATION ®. <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACFj TANK. <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED yy <br /> FACILITYISITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO ❑ �1 <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY •� <br /> A. OWNERS TANK ID If B. MANUFACTURED BY: <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: <br /> 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> �i <br /> A. ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM S. C. ❑ 1 UNLEADED ❑ 2 LEADED 0 3 DIESEL <br /> ❑3 CHEMICAL PRODUCT �O1L <br /> 1 P ODUCT ❑ 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> ❑5 HAZARDOUS ❑ 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 _ <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.9 w a s fe Q /` C.A.S.#: ©S <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLYIN BOx A,B,C,AD <br /> A.TYPE OF ❑ 1 DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN <br /> SYSTEM SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> STEELPRON 2 STAINLESS STEEL ❑3 FIBERGLASS 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC <br /> B.TANK <br /> MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM 8 100%METHANOL COMPATIBLE FRP <br /> ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN 99 OTHER <br /> C.INTERIOR <br /> ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING <br /> LINING ❑ 5 GLASS LINING Elf'ALINED ❑%UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO 99 OTHER <br /> D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑5 CATHODIC PROTECTION [L> NE ❑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 .0 2 PRESSURE A(CU3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B.CONSTRUCTION U 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 /> 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 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZEDSTEEL 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 /> I VISUAL CHECK P S2 INVENTORY RECONCILIATION P 5 3 SE WELLS P,S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS <br /> 6 PRECISION TESTING P S 7 PRESSURE TESTING 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/YRI 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH <br /> I SUBSTANCE REMAINING IN GALLONS I <br /> 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 /> 3 , <br /> I I I I El I 1 10 12 P) I /-,-I Lolo-Fo lo4 <br /> CURRENT LOC41-AGENCY FACILITY ID k J APPROVE BY NAM `jfj PHONE s WITH AREA CODE <br /> PERMIT HUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK 11 PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: <br /> -71 <br /> ` w <br /> FORM B(fi-29-88) THIS FORM MUST BE ACCOMPANk."Y A FACILITYISITE APPLICATION, FORM `A',UNLESS ItRENT FORMA' HA5 BEEN FItEd <br /> DATA PROCESSING COPY <br />