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'ATE OF CALIFORNIA WATER RESOURCES CONTROL So ° <br /> ORM `B': UNDERGROUND STORAGE TANK PROGR M <br /> TANK PERMIT APPLICATION INFORMATI `` <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING I MOTION FOR EACH � <br /> TANK <br /> MARK ONLY I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TA I <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT B TEMPORARY TANK CLOSURE a TANK REMOVED , <br /> ' FARM TANK-YES❑ NO C Ti <br /> JkCILITY/SITE NAME WHERE TANK IS INSTALLED: 47 <br /> NK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY O <br /> OWNERS TANK ID# Q B. MANUFACTURED BY <br /> C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: !DO <br /> I1. TANK CONTENTS If(A.1),IS MARKED,COMPLETE ITEM C.IF(A.t),IS NOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTORVEHICLEFUEL ❑ 2 PETROLEUM B. C.. 1 UNLEADED 2 LEADED 3 DIESEL <br /> ❑3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT E] T FUEL 6 AVIATION GAS <br /> 4 GASOHOL 5 JE <br /> ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN 2 WASTE ❑7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> pl D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C•A"S;.#: „/�A <br /> HAZARDOUS SUBSTANCE STORED 8,C.A.S.# 4' <br /> r' III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.6,C,a D <br /> A.TYPE OF ❑ 1 DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN <br /> SYSTEM EXSINGLEWALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> 1 [9^1•STEELIIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC <br /> B.TANK ❑5 CONCRETE. ❑6 POLYVINYLCHLORIDE .❑7 ALUMINUM 6 100%METHANOLCOMPATIBLEFRP <br /> MATERIAL ❑y BRONZE 10 GALVANIZED STEEL [D,95 UNKNOWN ❑99 OTHER <br /> i I RUBBERUNED ❑ 2 ALKYD LINING 3 EpOXYUNING ❑4 PHENOLICLINING <br /> C.INTERIOR ❑ 5 GLASS LINING 6 UNLINED 95 UNKNOWNS <br /> ❑ IS LINING MATERIAL COMPATIBLE WITH IDD%METHANOL? YES 0 NO 52^99 OTHER <br /> i1 POLY£TTiLENE WRAP 2 TAR OR ASPHALT ❑3 VINYL WRAP E]4 FIBERGLASS REINFORCED PLASTIC <br /> D.CORROSION ❑ ❑ <br /> PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE �5 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMAT ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE ih <br /> A SYSTEM TYPE AIV 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 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 /> I <br /> C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 1 OD%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A 5 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 2 INVENTORY RECONCILIATION „P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS v <br /> P SO PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P B 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1• ESTIMATE DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY F 3.WAS ANK FILLED WITH <br /> SUBSTANCE REMAI G I ! E ATERIAL? YES ❑ NO <br /> LA GALLON8 <br /> THIS fjORM HAS BEEN COMPLETED UNDER PENALTY OF PERJU AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION q AGENCY# FACILITY ID M TANK ID# <br /> P 1 <br /> CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAME PHO010 NE M WITH AREA CODE <br /> Le L.>7U / 7 <br /> PERMIT NUMBER PERMIT RO AL ATE PERMIT )(PIRATION DATE <br /> CHECK M PERMIT AMOUNT SURCHARGE A T. FEE CODE, F ECEIPT M BY: <br /> RIM B(s-2s 6B) 1Ti1S FORM Ml�sr BE ACCOMPA�N`Iii)_BY A FACILETYISITE APPLICATION, FORM`A',UNLESS'A •URRENT FORIPA'.HAS BEEN FILED <br /> - �_ - -- <br />