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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `B': STORAGE TANK PROGRAM <br /> TANK T IT PPLICATION INFORMATION <br /> COMPLE E T ORM H THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY 1 NEW PERMIT <br /> ONE ITEM ❑3 RENEWAL PERMIT EF]5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK <br /> ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: <br /> FARM TANK-YES NO -�. <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY ;Cj <br /> A. OWNERS]TANK ID# ' B. MANUFACTURED BY: <br /> C. YEAR INLLED D. TANK CAPACITY IN GALLONS: 60 <br /> Ii. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. p0 <br /> A. �1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED [j;-l"LEADED ❑ 3 DIESEL <br /> ❑3 CHEMICAL PRODUCT ❑4 OIL � <br /> U ' PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS <br /> ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.N /A <br /> C.A.S.N: <br /> x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN <br /> SYSTEM ff 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER <br /> TANK �'I STEEL/IRON ❑2 STAINLESS STEEL F-13 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP <br /> ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER <br /> ❑ <br /> C. INTERIOR 1 RUBBER LINED F-12 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING <br /> "'�l <br /> LINING ❑ 5 GLASS LINING t1UNLINED ❑ 95 UNKNOWN <br /> ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑ 99 OTHER <br /> D. CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑5 CATHODIC PROTECTION LTJ '1 NONE ❑ 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 _97 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE <br /> C.MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <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 /> ap6i <br /> VISUAL CHECK P S2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAIT USED(MO/YR) J17SUBSTANCEQRE <br /> DUANTI OF 3, WAS T K FILLED WITH <br /> INI y�N IN RT �11�RIAL? E] YES ❑ NO <br /> Jy GALLONS T� <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TOTHE BEST OF MY KNOWLE GE, IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID#111-? <br /> CURRENT LOCAL AGENCY FACILITY ID k APO EDB NAME �, PHONE k WITH AREA CODE <br /> PERMIT NUMBER PERMIT.A�%PP OV L DATE PERMIT EXPIRATION DATE <br /> l l/- <br /> ---[CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE "`CEIPT k BY: <br /> FORM 8(3-7-88) THIS FORM MUST BE ACCOMPANIia7roY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A cuRRENT FORM'A' MAS BEEN FILED <br />