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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `B': UNDERGROUND STORAGE TANK PROGRAM <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. o <br /> EMARK;;;jW PERMIT ❑3 RENEWALPERMIT 10 <br /> ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK <br /> ERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ TANK REMOVEDANK IS INSTALLED: <br /> - FARM TANK-YES❑ NO <br /> I. TANK DESCRIPTION COMPLETE ALL.ITEMS-OF UNKNOWN—SO SPECIFY <br /> A. OWNERS TANK!D# <br /> C. YEAR INSTALLED �[ {,( B. MANUFACTURED BY: <br /> 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 g <br /> C ❑+ '1 UNLEADED ❑2 LEADED ❑3 DIESEL <br /> ❑3 CHEMICAL PRODUCT ❑4 OIL �( PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS <br /> ❑5 HAZARDOUS ❑ BO 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&C.A.S.N <br /> C.A.S.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D <br /> FA-TYPEOF ❑ 1 DOUBLEWALLED ❑3SINGLEWALLEDWITHEXTERIORLINER ❑ 95 UNKNOWN <br /> EM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER <br /> ❑� STEELIIRON ❑2 STAINLESS STEEL ❑3 RBERGLASS4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> RIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑6 100%METHANOLCOMPATIBLEFRP <br /> ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER <br /> C. INTERIOR I RUBBER LINED ❑2 ALKYD LINING ❑3 EPOt(LINING ❑4 PHENOLIC LINING <br /> LINING ❑ 5 GLASS LINING Eg-"NLINED ❑95 UNKNOWN <br /> ❑fS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER <br /> D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑5 CATHODIC PROTECTION ❑ 91 NONE ERZ UNKNOWN ❑ 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE}/ <br /> A SYSTEM TYPE A.U 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 U25 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 B 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A CU.-b5 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 S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 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 /> 1 SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? [:]YES E] NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION k AGENCY# FACILITY ID# TANK ID# <br /> Lt D I d TT El t, <br /> I <br /> T 1-1 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> r <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ' <br /> CHECK# PERMIT AMOUNT NURCHARGE AMT, FEE CODE RECEIPT# BY: <br /> FORM B(6-29-66) THIS FORM MUST BE ACCOMPANIED FY-A FACiL1TY1SITE APPLICATION, FORM `A',UNLESS A CUR ENT FORMA' HAS BEEN FILED , <br /> LOCALAGENCY COPY <br />