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._.. ..-,.�+.�.nrw"'W'�"*fir^-.-r;'s.�r..-.,�:�`e'�r.,r•.S7' -�'�'�?'""'°}'�Y7TS^",�'4s.ve•+0;�^�:�.-"T--. ....:^,r-n.-!+mw.•+.+r;iT?"^�v.-.t�'^.-"'To^�, .r—�--++---'-J!-i--+-,+-.--r+.-7s- <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL 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 Tfl NEW PERMIT F-�3 RENEWAL PERMIT f--j 5 CHANGE OF INFORMATION F-1 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM F-1 2 INTERIM PERMIT F-1 4 AMENDED PERMIT [::]6 TEMPORARY TANK CLOSURE 0 8 TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: Z O RM TANK-YES❑ NO z <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY i O <br /> A. OWNERS TANK IDNf)K B. MANUFACTURED <br /> C. YEAR INSTALLED I cl 11b I D. TANK CAPACITY IN GALLONS: <br /> W <br /> 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. Q� <br /> A. [--] 1 MOTOR VEHICLE FUEL F-�2 PETROLEUM B. C. 1 UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT U 'OIL ❑ 1 ODUCT F-14 GASAHOLV9JOTHER <br /> FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS [:] 80 EMPTY [_ 95 UNKNOWN 2 WASTE El 7 METHANOL (DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S. mer <br /> # le <br /> / C.A.S.N: <br /> All. TANK CON RUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A TYPE OF 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED 4 SECONDARY CONTAINMENT El 99 OTHER <br /> 1 STEEUIRON ❑2 STAINLESS STEEL 3 FIBERGLASS F-1 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM 8100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED 2 ALKYD LINING F-1 3 EPDXY LINING n/PHENOUC UNING <br /> C.INTERIOR ❑ "W/� <br /> LINING 5 GLASS LINING 6 UNLINED 95 UNKNOWN <br /> IS UNING MATERIAL COMPATIBLE WITH 100%MEDIANOL? 0 YES ONO 99 OTHER <br /> D.CORROSION ❑1 POLYETHLENE WRAP 2 TAR OR ASPHALTVINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION [-]5 CATHODIC PROTECTION 91 NONE 19 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 PRESSURE A P3 GRAVITY A U 99 OTHER <br /> B.CONSTRUCTION A U 1 SINGLE WALLED U DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNPOYN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) Jf U FIBERGLASS PIPE <br /> C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP 8 1 DO%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER <br /> L V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLCS 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS <br /> P 8 8 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH <br /> GALLONS <br /> SUBSTANCE REMAINING IN 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 /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY M FACILITY IDM TANK ID M <br /> Et <br /> 1014911 0 © o <br /> CURRENT LOCAL AGENCY FACILITY 10N APPROVED BY NAME HO E N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK• PERMIT AMOUNT SURCHARGE AMT. FEE CODE ---ECEIPT N BY: <br /> 1 FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM'A',UNLEIt <br /> URRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />