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STATE OF CALlFORI WATER RESOURCES CONT*BOARD 5•�;. <br /> `,!► m <br /> ` .FORM `B': UNDERGROUND STORAGE TANK PROGRAM <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> GOMRLETE A'SEPARATE FORM WITH THE FOLLOWING ORMATION FOR EACH TANK. <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E]7 PERMANEN CLOSED T <br /> ONE ITEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE E]8 TANK RE VIED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: ® VI), FARM TANK 4YES❑ NO <br /> L TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK IDA Z B. MANUFACTURED BY: �J CJS <br /> C.YEAR INSTALLED U(l/ D. TANK CAPACITY IN GALLONS: <br /> 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. } <br /> A. 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. 1 UNLEADED 2 LEADED F-�3 DIESEL <br /> 3 CHEMICAL PRODUCT 4 OIL 1 PRODUCT ❑4 GASAHOL 5 JET FUEL F-1 6 AVIATION GAS <br /> 5 HAZARDOUS 80 EMPTY [-]95 UNKNOWN 2 WASTE 7 METHANOL E]99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.A C.A.S.M <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF FT DOUBLE WALLED F-�3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM E]2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEEUIRON 2 STAINLESS STEEL r-1 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK 15 CONCRETE 6 POLYVINYLCHLORIDE ❑1 ALUMINUM 8 100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> ❑9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> C.INTERIOR I RUBBER UNED 2 ALKYD UNING 3 EPDXY LINING ❑4 PHENOLIC LINING <br /> LINING 0 5 GLASS LINING 6 UNLINED F-�95 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES Ej NO [:]99 OTHER <br /> D.CORROSION ❑1 POLYETHLENE WRAP 2 TAR OR ASPHALT F-�3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 91 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 U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A .0 95 UNKNOWN A U 99 OTHER <br /> 0.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 /> A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C.MATERIAL A U 5 ALUMINUM A U 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 /> IP 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING 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 LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF 3,WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS 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 /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY x <br /> [ERMIT <br /> NTY.II JURISDICTION II AGENCY A FACILITY ID A TANK ID A <br /> 1 7 -� F7 <br /> OCAL AGENCY FACILITY 10 Y APPROVED BY NAME PHONE M WITH AREA CODE <br /> F MBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY; <br /> FORM B(6-29-66) THIS FORM MUST BE ACCOMP Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS..CURRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />