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STATE OF CALIFOROA WATER RESOURCES CON*L BOARD <br /> FORM 'B': UNDERGROUND STORAGE TANK PROGRAM <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 CHANGE OF INFORMATION z <br /> ONE ITEM ❑ 7 PERMANENTLY CLOSED TANK <br /> 2 INTERIM PERMIT 4AMENDED PERMIT 6 TEMPORARY TANK CLOSURE <br /> 8 TANK REMOVED /s <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: S; -/ FARM TANK-YES NO N <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY CTT <br /> A. OWNERS TANK ID NOD <br /> / CIO <br /> B. MANUFACTURED BY: <br /> 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. 3 <br /> A. F-] 1 MOTORV ICLE FUEL � 2 PETROLEUM B. C 1 UNLEADED <br /> ❑ 2 LEADED 3 DIESEL <br /> 3 ICAL PRODUCT q OIL 1 PRO 0 4 GASAHOL E] 5 JET 6 AVIATION GAS <br /> 5 HAZARDOUS El 80 EMPTY 0 95 UNKNOWN WASTE Ej 7 METHANOL 9 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED 8 C.A.S.# / <br /> -STC[ A.S.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D <br /> FB. TANK <br /> E OF EC <br /> E]3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> TEM E]4 SECONDARY CONTAINMENT <br /> 99 OTHER <br /> 25TAINLESS STEEL 3� 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> ERIAL 6 POLYVINYLCHLORIDE 7 A UM 6100%METHANOL COMPATIBLE FRP <br /> Ej 10 GALVANI TEEL 95 UNKNOWN 0 99 OTHER <br /> C. INTERIOR 1 RUBBER LINEDKYD LINING 3 EPDXY LINING 0 4 PHENOLIC LINING <br /> LINING ❑ 5 GLASS LINING 6 UNLINED g5 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL?.- E]YES E]NO 099 OTHER <br /> D.CORROSION ❑ 1 POLYEIHLENE WRAP ❑2 T ASPHALT 0 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 91 NONE E195 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROU D TH IF APPLICABLE <br /> A.SYSTEM TYPE A U 1 SU TIO A U 2 PRESSURE A 3 c ITY <br /> B.CONSTRUCTION A 1 SIN ALLED A U 2 DOUBLE WALLED A U 3 INED TRENCH A U 91 NONE A lk�U 95 UNKNOWN U 99 OTHER <br /> A U N A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPTFE— A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUM A U <br /> A U ] STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A 95 LINKNO N 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 1VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S ] PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P $ 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MO/YR) , ESTIMATED QUANTITY , <br /> SUBSTANCE REMAINING IN 3. WAS TANK FILLED WITH <br /> GALLONS 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 8 SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# <br /> FA ID# TANKID# <br /> a� O v o o a / <br /> / CURRENT LOC NCY FACILITY IDN <br /> �) APPROVED BY NAME PHONE N WITH AREA CODE <br /> V PERMIT NUMBER PERMIT APPROVAL DATE <br /> PERMIT EXPIRATION DATE <br />\ CHECK# PERMIT AMOUNT $URCHARGEAMT. <br /> dlIkkl FEE CODE REC TN $ . <br /> FORM B(6-29-SB) THIS FORM MUST BE ACCOMPANIED ByAnCILITYISITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FI� <br /> DATA PROCESSING COPY <br />