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STATE OF CALIFORt* WATER RESOURCES CONT. BOARD <br /> FORM `B': UNDERGROUND STORAGE TANK PROGRAM <br /> TANK PERMIT APPLICATION INFORMATION <br /> TANK � <br /> COMP TE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> 11 <br /> MARK ONLY1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM [:]2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE E]8 TANK REMOVED D <br /> G <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES E] NO E] f-- <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-6/o/SPECIFY 0 <br /> A. OWNERS TANK ID q oqB. MANUFACTURED BY: n <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 3 <br /> f Iwo <br /> 11. TANK PiONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,CGiAPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL M 2 PETROLEUM C. 1 UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT E]4 OIL RODUCT E]4 GASAHOL 5 JET FUEL E] 6 AVIATION GAS <br /> 5 HAZARDOUS 0 80 EMPTY [D 95 UNKNOWN [V::]2 WASTE 11 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.N C.A.S.II: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B.C.i D <br /> A.TYPE OF ❑ 1 9OLMLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM WALLED 4 SECONDARY CONTAINMENT E]99 OTHER <br /> 1 STEELARON 2 STAINLESS STEEL 3 FIBERGLASS M 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK <br /> MATERIAL 5 CONCRETE 6 POLYVINYLCHLORIDE 7 ALUMINUM E]8 100%METHANOL COMPATIBLE FRP <br /> 9 BRONZE 10 GALVANIZED STEEL E]95 UNKNOWN E]99 OTHER <br /> C.INTERIOR ❑ I RUBBER LINED ED2 ALKYD LINING 3 EPDXY LINING E]4 PHENOLIC LINING <br /> LINING ❑5 GLASS LINING M 6 UNLINED E]95 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES [:] NO [:]99 OTHER <br /> D.CORROSION ❑I POLYEFHLENE WRAP 2 TAR OR ASPHALT 3 VINYL WRAP E]4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 91 NONE E]95 UNKNOWN E]99 OTHER <br /> IV- PIPING INFORMA ION 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 U 95 UNKNOWN A U 99 OTHER <br /> B.CONSTRUCTION A IV 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 STEELARON 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 /> P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 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 INERT MATERIAL? E]YES E]NO <br /> 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 6 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> FCOUNTY M JURISDICTION N AGENCY# FACILITY II-D q TANK ID N <br /> EE] I- I I�J F-[- 1 -1- - LlLP <br /> CUFF I I �l <br /> RRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME HONE N WITH AREA CODE <br /> � /0 W2�: <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT IR/IIOVND <br /> -T <br /> CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: <br /> FORM B(6-29.66) THIS FORM MUST BE ACCOMPANiEU BY A FACILITY/SITE APPLICATION, FORM 'A',UNLE$S A CURRENT FORMA' HAS BEEN FILED <br /> IN DATA PROCESSING COPY <br />