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� ori <br /> 1 H6�..e�eiei,ekE.. <br /> STATE OF CALIFORNUO WATER RESOURCES CONTROVA <br /> AnRD l` il R,a <br /> FORM 'B': UNDERGROUND STORAGE TANK <br /> TANK PERMIT APPLICATION INFORMATION77 <br /> TAN COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK, r""`°""\� <br /> I NEW PERMIT 1:33 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED TANK <br /> MARK ONLY 6 TEMPORARY TANK CLOSURE ❑ K REMOVED <br /> 8 TAN <br /> ONE ITEM � 2 INTERIM PERMIT El 4 AMENDED PERMIT Via,? <br /> FARM TANK-YES D NO I <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: ) <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY <br /> B. MANUFACTURED BY'. <br /> [C]YEEARI <br /> TANK ID <br /> p. TANK CAPACITY IN GALLONS'. <br /> TALLED <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> B C. � 1 UNLEADED � 2 LEADED � 3 DIESEL <br /> A. Q 1 MOTOR VEHICLE FUEL F-] 2 PETROLEUM <br /> 3 CHEMICAL PRODUCT [—] 4 OIL <br /> 1 PRODUCT 4 GASAHOL 0 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS Ej 80 EMPTY [:]95 UNKNOWN 0 2 WASTE 7 METHANOL D 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF CA,S.q, <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 D I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER p 95 UNKNOWN <br /> SYSTEM El 2 SINGLE WALLED 4 SECONDARY CONTAINMENT <br /> 99 OTHER <br /> F1 I STEEL/IRON 2 STAINLESSSTEEL F-] 3 FIBERGLASS 4 STEEL CLAD WIFIBERGLASSREINFORCEDPLASTIC <br /> B.TANK F-I 5 CONCRETE 6 POLYVINYLCHLORIDE ❑7 ALUMINUM 8 160%METHANOL COMPATIBLE FRP <br /> MATERIAL I0 9 BRONZE 10 GALVANIZED STEEL 0 95 UNKNOWN ❑99 OTHER <br /> ❑� <br /> l 1 RUBBER LINED 2 ALKYD LINING 0 3 EPDXY LINING 4 PHENOLIC LINING <br /> C. INTERIOR [:]5 GLASS LINING �8 UNLINED <br /> El ISLININGMATERIAL COMPATIBLE WITH 100%METHANOL? 0 YES 0 NO 99 OTHER <br /> D.CORROSION Q 1 POLYETHLENE WRAP F] 2 TAR OR ASPHALT [:] 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION Ej 5 CATHODIC PROTECTION El 91 NONE El 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 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 WALLED A U 3 LINEOTRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/00N A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U B FTSERGLASSPIPE METHANOL CO A UIBLE ERP91 NE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD WfFRP <br /> A U 9 GALVANIZED STEEL 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 /> P S i VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR a S 5 GROUND <br /> WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING <br /> P S 91 NONE P S 95 UNKNOWN <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.was TANK FILLED WITH <br /> L ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF INERT MATERIAL? ❑YES NO <br /> SUBSTANCE REMAINING IN GALLONS <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> DATE <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# <br /> FACILITY ID# TANK ID# <br /> LI= ICURRENT LOCAL AGENCY FACILITY 96# <br /> APP VED BY NAME PHONE#WITH AREA CODE <br /> PERMIT PR VAL DA PERMIT EXP TION D E <br /> PERMIT NUMBER <br /> CHECK# PERMIT AMOUNT SURCHARGE MT. <br /> FEE CODE RECEIPT <br /> FORM B(6-29-8s) THIS FORM MUST BE ACCOMPANIE Y A FACILITYISITE APPLICATION, FO RM `A',UNLESS ATTRRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />