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�f'`.. ;,'�• <br /> STATE OF CALIFORNIP ARD <br /> WATER RESOURCES CONTRO �� � <br /> FORM `B': UNDERGROUND STORAGE TANK PRO AM u ° �o <br /> TANK PERMIT APPLICATION INFORMATION ati, <br /> TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK- z <br /> 1 NEW PERMIT � 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> MARK ONLY ❑ <br /> ONE ITEM � 2 INTERIM PERMIT E]4 AMENDED PERMIT 06 TEMPORARY TANK CLOSURE 6 TANK REMOVED C� <br /> FARM TANK-YES❑ NO00 <br /> TV <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: l <br /> TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> B. MANUFACTURED BY: <br /> A. OWNERS TANK ID# <br /> D. TANK CAPACITY IN GALLONS: <br /> C.YEAR INSTALLED <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. 0 1 MOTOR VEHICLE FUEL Q 2 PETROLEUM <br /> B. C. � 1 UNLEADED 0 2 LEADED �3 DIESEL <br /> 3 CREMICALPRODUCT � 4 OIL El <br /> 1 PRODUCT ❑4 GASAHOL 0 5 JET FUEL E 6 AVIATION GAS <br /> 5 HAZARDOUS D 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE 7 METHANOL D 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> 1 DOUBLE WALLED fl 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> A.TYPE OF ❑ ❑99 OTHER <br /> SYSTEM 2 SINGLE WALLED 4 SECONDARY CONTAINMENT <br /> a 1 STEELIIRON Q 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD WIFI6ERGLASS REINFORCED PLASTIC <br /> B. TANK 5 CONCRETE � 6 POLYVINYLCHLORIDE 7 ALUMINUM 6 100%METHANOL CCMPATBLE FRP <br /> MATERIAL E]9 BRONZE 10 GALVANIZEDSTEEL 0 95 UNKNOWN � 99 OTHER <br /> 1 RUBBER UNED 2 ALKYD LINING D 3 EPDXY LINING 4 PHENOLIC LINING <br /> C. INTERIOR ❑ E1 95 UNKNOWN <br /> LINING 5 GLASS LINING 6 UNLINED <br /> ISLININGMATE91ALCOMPATIBLEWITH100%METHANOL? ]YES NO ❑99 OTHER <br /> D. CORROSION F-1 I POLYETHLENE WRAP F_� 2 TAR OR ASPHALT Ej 3 VINYL WRAP El 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION F-1 5 CATHODIC PROTECTION E] 91 NONE ❑ 95 UNKNOWN E] 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A.SYSTEM TYPE !AU 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U99 OTHER <br /> B. CONSTRUCTION f5ALUMINUM <br /> GLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> ELl1RON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC} A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C. HIATERIAL A U 6 CONCRETEA U 7 STEEL CLADWIFRPA U 6 100%METHANOLCOMPATIBLEFRP <br /> LVANIZED 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 1 VISUAL CHECK P S 2 VNVENTORY RECONCILIATION P S 3 VADOSE WELLS P 5 4 ELECTRONIC MONkTOR fp <br /> 9�SGROUNO WATER MONITORI�WELLS <br /> P S 6 PRECIShON TESTING P 5 7 PRESSURE TESTING P S 91 NONE <br /> P S 95 UNKNOWN <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3,WAS TANK <br /> 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY G I INERT MATERIAL? DYES 0 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 /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# <br /> FACILITY ID# TANK ID# <br /> E=� <br /> �� <br /> PHONE is WITH AREA CODE <br /> CU RENT LOCAL AGENCY FACILITY ID q APP ED BY NAME <br /> PERMIT PPRO L DATE PPAMIT EXPIRATIOW10ATE <br /> PERMIT NUMBER <br /> CNECK# PERMIT AMOUNT SURCHARG AMT. <br /> FEE CODE RECEIPT# BY: <br /> FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIMMY A FACILITY/SITE APPLICATION, FO R M `A',UNLESS A111FRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />