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STATE OF CALIFORNlib WATER RESOURCES CONTROARD <br /> FORM B': UNDE ROUND STORAGE TANK PRO AM N <br /> TANKTANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ^" Z <br /> IQ <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑7 URMANENTLY CLOSED TANK <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED BLr <br /> GL1 <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: ' FARM TANK-YES❑ NO IIV <br /> I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: <br /> C. YEAR INSTALLED D. TANK CAPACITY INGALLONS: d� <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,C5>MPLETE ITEM D. <br /> A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. UNLEADED ❑ 2 LEADED ❑3 DIESEL <br /> ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑ 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 /> 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.I C.A.S.#: <br /> III. TANK CONSTRUCTION MARK 04 ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF ❑ 1 DOUBLEWALED ❑ SINGLEWALLED WITH EXTERIOR LINER ❑95 UNKNOWN <br /> SYSTEM ❑2 SINGLE WALLED ❑4 ECONOARY CONTAIN MEM ❑ 99 OTHER <br /> ❑ 1 STEEUIRON ❑2 8 INLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CUD W/RBERGUSS REINFORCED PLASTIC <br /> B.TANK ❑ 5 CONCRETE ❑6 POL NYLCHLORIOE ❑ 7 ALUMINUM ❑8103%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> ❑ 9 BRONZE ❑ 10 GAL NIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER <br /> ❑ 1 RUBBER UNED ❑2 ALKYD LI ING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING <br /> C.LININ INTERIOR 5 GLASS LINING 6 UNUNED ❑95 UNKNOWN <br /> LINING ❑ ❑ <br /> ❑ IS UNING MATERIAL COMPATIBLE WITH 100%MET OL? ❑YES ❑ NO ❑ 99 OTHER <br /> D. CORROSION ❑ I POLYETHLENEWRAP ❑2 TAR OR ASPHAL ❑ 3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUN , U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 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 WA ED 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 ST EL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD WERE 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,ORS OR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOS WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN LACE <br /> I. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY 0 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING I <br /> GALLONS INERT MATERIAL? ❑YES ❑ NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,A 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 /> 71010101 / 1 <br /> CURRENT LOCAL AGENCY FACILITY ID APPRO ED BYNA E Q(�� PHONE#WITH AREA CODE <br /> u_ � �/ L <br /> PERMIT NUMBER PERMIT APPROVAL DATE PIIRMIT EXPIRATION DATE <br /> r CHECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY: <br /> FORM B 16-29-Bal THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM'A' HAS BEEN FILED !� <br /> DATA PROCESSING COPY <br />