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STATE OF CALIFORN16 WATER RESOURCES CONTROARD <br /> UNDERGROUND STORAGE TANK PRO AM '� <br /> FORM `B': <br /> TANK TANK PERMIT APPLICATION INFORMATION a, <br /> CQMPLETE A SEPARATE FORM WITH THE FOLLOWING FORMATION FOR EACH TANK. <br /> MARK ONLY I NEW PERMIT F-I 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 N <br /> FARM TANK-YES F-] NO <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> N <br /> A. OWNERS TANK ID# B, N4ANUFACTURED BY: <br /> C. YEAR INSTALLED D, TANK CAPACITY IN GALLONS: �} (� <br /> II. TANK NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTORVEHIGLEFUEL 2 PETROLEUM :iEl C. ❑ 1 UNLEADED � 2 LEADED ESEL <br /> 3 CHEMICAL PRODUCT 714 OIL PRODUCT4 GASAHOL El 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS Ej BO EMPTY E]95 UNKNOWN WASTE 7 METHANOL El 99 OTHER(DESCRIBE:IN ITEM D,BELOW) <br /> D, IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.4: <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A TYPE OF ❑ 1)R&E WALLED 3 SINGLE WALLED WITH EXTEHIOR LINER 95 UNKNOWN <br /> SYSTEM SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> TEELIIRON D 2 STAINLESS STEEL a 3 FIBERGLASS [j 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE [::] 7 ALUMINUM 8 106%METHANOL COMPATI6LEFRF <br /> MATERIAL <br /> 9 BRONZE [::] 14 GALVANIZED STEEL E] 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED F-I 2 ALKYD LINING F-] 3 EPDXY LINING 4 PH EN LIG LINING <br /> C. INTERIOR L� 5 GLASS LINING �6 UNLINED (KNOWN <br /> LINING J <br /> IS LINING MATERIAL COMPATIBLE WITH 16O%METHANOL? ❑ YES Ej NO E]99 OTHER <br /> D. CORROSION 1 POLYETHLENE WRAP F-] 2 TAR OR ASPHALT ❑ 3 VINYLWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION ❑91 NONE S UNKNOWN Ej 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A 1 SUCTION P PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> A.SYSTEM TYPE <br /> B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH A U 91 NONE U 5 UNKNOWN A U 99 OTHER <br /> A U 1 STEELIIRON 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 W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL 5 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 /> VISUAL CHECK 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> X..� P �6 PRECISION TESTING P 5 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 /> i. ESTIMATED DATE LAST SED MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN. INERT MATERIAL? YES NO <br /> GALLONS <br /> THIS FORM HAS 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 /> 1 � e 6o <br /> CURRENT LOCAL AGENCY FACILITY IDR <br /> APPROVED BY N ONE#WITH AREA CODE <br /> LPERMITNUMBER PERMIT APPROVALDATE RMIT E (RATION DATE <br /> PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: <br /> 1 <br /> FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIE o A FACILITY/SITE APPLICATION, FORM `A',UNLESS A RENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />