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STATE OF CALII%,,dRNIA WATER RESOURCESwJNTROL BOARD •':w:,'� <br /> f FORM 'B': ...UNDERGROUND STORAGE TANK PROGRAM <br /> UNK PERMIT APPLICATION INFORMATION ` <br /> TANK (1,/COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ` <br /> MARK ONLY E:] I NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM 2 INTERIM PERMIT 1 AMENDED PERMIT 8 TEMPORARY TANK CLOSURES TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: Al- ARM TANK-YES❑ NO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—80 SPECIFY <br /> A. OWNERS TANK ID N B. MANUFACTURED BY: <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: <br /> 11. TANK CONTENTS IF(A.1),18 MARKED,COMPLETE ITEM C.IF(A.1),19 NOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL �2 PETROLEUM B.Ej <br /> C. 1 UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT OIL M 1 PRODUCT ❑4 GASAHOL E:]5 JET FUEL 8 AVIATION GAS <br /> 5 HAZARDOUS E]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 N1 CA.S.N C A.S.N: <br /> ,., Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D <br /> A.TYPE OF ❑1 DOUBLE WALLED 3 SINGLE WALLED WTIH EXTERIOR LINER 95 MW40WIN <br /> SYSTEM ❑2 W W WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER <br /> c.r E] 1 STEEL/IRON 2 STAINLESS STEEL 3 RBEI ASS /STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> 8.TANK 5 coNcaErE 8 POLYVINYLCHLORIDE Cj 7 ALUMINUM B 100%METWWOLCOWATIBLEFIP <br /> MATERIAL <br /> ❑9 BZE ❑ 10 GALVANIZED STEEL ❑95 uwlLNowN o aTHER <br /> RDN <br /> ❑I(TANNER UINED o 2 AIXYD UNNG o 3 EPDXY LINING o M PHENOLIC LING <br /> C.INTERIOR <br /> K NOR <br /> LI ❑5 GLASS LINING 8 UNLINED 095 UWNOWN <br /> ISLIMO MATERIAL COMPATIBLE WITH 19ou WTHANOL4 ❑YES [:1 NO 99 OTHER <br /> 0.CORROSION ❑I POLYETHLENE WRAP ❑2 TAR OR ASPHALT []3 VINYL WRAP /FIBERGUSS REIIFORCEO PLASTIC <br /> PROTECTION E]5 CATHODIC PROTECTION E:]91 NONE 95 UNKNOWN 99 OTHER <br /> y IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A.SYSTEM TM A U 1 SUCTION A .0 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> S.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> Lr A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U I FIBERGLASS PIPE A U 91 NONE <br /> C.MATERIAL A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 1009 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 /> P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELL! <br /> P 8 8 PRECISION TESTING P 8 1 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 OUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? YES [D NO <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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> EPl7RMffHUMBfR <br /> JURISDICTION N AGENCY N FACILITY ID N TANK ID N <br /> ,.r J <br /> I �1� [ I I _ld. <br /> AGENCY FACILITY ID• APPROVED BY NAME PHONE 0 WITH AREA CODS <br /> .r <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION CATS <br /> PERMIT AMOUNT BUIICHAROE AML FEE CODE RECEIPT N BY: <br /> �� ���..s.e ,,e., TueQ*nou �Htr ne ierrtaoitrme a..teen ITVMRt aea Ie�nnu FARU 'A' IIW CCQ A M'k wENT FORMA' IUS BEEN FILED <br />