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' STATE OF CALIFORN ...: ,� . <br /> WATER RESOURCES CONTR OARD <br /> FORM 'B': UND ROUND STORAGE TANK PRAM . <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY ❑1 NEW PERMIT 3 RENEWAL PERMIT <br /> ONE ITEM ❑5 CHANGE OF INFORMATION El"$PERMANENTLY CLOSED TANK <br /> 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE <br /> NK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: <br /> FARM TANK-YES NO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-if UNKNOWN—80 SPECIFY Z ' <br /> --E <br /> ry <br /> A. OWNERS TANK 10# B. MANUFACTURED BY: lC— ' <br /> C. YEAR INSTALLED <br /> D. TANK CAPACITY IN GALLONS:aEL==��E^b I <br /> I <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. (~� <br /> 1 UNLEADED L_j 2 LEADEDESEL 3"s <br /> 3 CHEMICAL PRODUCT 4 OIL RODUCT ❑4 GASAHOL ❑5 JET FUEL [:D 6 AVIATION GAS <br /> 5 HAZARDOUS 80 EMPTY [:]95 UNKNOWN 2 WASTE 0 7 METHANOL 0 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# <br /> C.A.S.#: <br /> x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D <br /> A.TYPE OF ❑ 1 WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ED95 UNKNOWN <br /> SYSTEM SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER&TANK ` <br /> 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC <br /> MATEM 5 CONCRETE ❑6 POLYVINYL CHLORIDE 7 ALUMINUM B 100%METHANOL COMPATIBLE FRP <br /> 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER I <br /> C.IMiERIOR Elj-mER UNED 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> LINING ❑5 GLASS LINING 6 UNLINED 95 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%MEMWL? YES ❑NO 99 OTHER <br /> 0.COON F-�1 POLYETHLENE WRAP D 2 TAR ORALT E]3 VINYL WRAP E]4 FIBERGLASS REINFORCED PLASTIC <br /> PAOTEL`tION DIC <br /> 5 CATHOPROTECTION �pYTIf95 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 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B.CMMUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE <br /> C.MATERIAL A 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U W OTHER <br /> j <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS <br /> P 8 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH { <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? DYES [—] No i <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. I <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> ) I <br /> L <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION N AGENCY#F FACILITY 10 N TANK IDN I <br /> LLI -1 Ldol / 1-31oP <br /> CURRENT LOCAL AGENCY FACILITY ID 1t APP DYED BY E PHONE A WITH AREA CODE <br /> /Zr !/ S'k <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> 1 <br /> i <br /> CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: <br /> I FORM a(3a-ee) THIS FORM MUST 8E ACCOMPANI A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORMA' HAS SEEN FILED <br /> DATA PROCESSING COPY <br />