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STATE OF CALIFORNIA WATER RESOURCES CONTR py <br /> ,•`'''' ``,, <br /> FORM `B': UNDERGROUND STORAGE TANK PR oo <br /> Ir TANK TANK PERMIT APPLICATION INFORMA O <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 ERMANENTLY CLO NK <br /> ONE ITEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 6 TANK REMOVED 9 W I <br /> �- FARM TANK-YES❑ NO N> <br /> _ FACILITYISITE NAME WHERE TANK IS INSTALLED: co <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> B. MANUFACTURED BY: l <br /> A. OWNERS TANK ID# Z <br /> C.YEAR INSTALLED 0. TANK CAPACITY IN GALLONS: c> <br /> II. TANK CONTENTS IF(AM,IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. ! <br /> B C. 1 UNLEADED LEADED 3 DIESEL <br /> A. MOTOR VEHICLE FUEL ❑2 PETROLEUM <br /> 3 CHEMICAL PRODUCT F-14 OIL 2 i PRODUCT ❑4 GASAHOL 5 JET,!FUEL 6 AVIATION GAS <br /> ❑5 HAZARDOUS SO EMPTY 95 UNKNOWN 2 WASTE ❑7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br />�I D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OFC.A.S.B: 7�L <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# ,t,//,4 <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A TYPE OF ❑ t USLE WAILED �3 SINGLE WALLED WITH EXTERIOR LINER F-195 UNKNOWN <br /> SYSTEM 2 SINGUEWALLED ❑4 SECONDARY CONTAINMENT 99 OTHER <br /> E STMELJIRON ❑2 STAINLESS STEEL. 3 FIBERGLASS E]4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC <br /> B.TANK Fj 5 CONCRETE a 6 POLYVINYLCHLORSDE F-1 7 ALUMINUM 8 1801E METHANOL COMPATIBLE FRP . <br /> MATERIAL <br /> 9 BRONZE 10 GALVANIZED STEEL E].95 UNKNOWN 99 OTHER <br /> ❑ i RUBBER LINED F-1 2 ALKYD LINING F-1 3 EPDXY UNING F-1 4 PHENOLIC LINING <br /> C.INTERIOR 5 GLASSUNING �UNLINEO ❑ 95 UNKNOWN <br /> LINING <br /> ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES [:]NO [�14 OTHER <br /> D.CORROSION ❑ 1 POLYETHLENE WRAP F-1 2 TAR OR ASPHALT 3 VIWLWRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION E]5 CATHODIC PROTECTION ❑91 NONE [.:_I'S UNKNOWN 99 OTHER <br /> IV. PIPING INFORMAf ION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> ar <br /> A SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A 91 NONE A U' 95 UNKNOWN A U 99 OTHER <br /> B.CONSTRUCTION A SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 91 NONE A Ui 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 P91 NONE <br /> C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD WIFRP A U 8 16046 METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZEDSTEEL 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 IBE CIRCLED. <br /> p S t VISUAL GHECK P S 2 kNVENTORY RECONCILIATION 3 YADOSE WELLS P S 4 ELECTRONIC MONITOR P S S.IGROUND WATER MONITORING WELLS + <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 1 NONE P S 95 UNKNOWN P S 99`OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE ST USED(MO/VRI 2.ESTIMATED OUANTI OF 3.WA TANKFFlLLED WITH <br /> SUBSTANCE REM ING IN IN T ATERIAL? [:]YES [:] NO <br /> GALLONS <br /> THIS FORM AS BEEN COMPLETED UNDER PENALTY OF PERJ RY,AND TO THE BEST OF MY KNO LEDGE,1S TRUE AND CORRECT. <br /> A?PLICANT'S NAME(PRINTED&SIGNATURE) , DATE i <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# - FACILITY ID# y TANK ID# <br /> I C210 <br /> CURRENT LOCAL AGEJNCY�FACILITY ID N � APPROVED$YIN E �pHONE I WITH AREA CODE � <br /> —FL ce <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPJIATION DATE <br /> CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE" RECEIPT N $Y: <br /> .( � fORM B{8-29-96) THIS FORM MUST BE ACCOAIPAI�IE ._ YOB A FACILITYI�PLICATION, FORM'A',UNLECORRENT FORMA' HAS BEEN FILED <br /> InAYA rnov _ ..... ...amu.. --- ; .� <br />