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STATE OF CALIFOR WATER RESOURCES CONT OARD t........... <br /> •i. 'f <br /> FORM `B': UND` ROUND STORAGE TANK P RAM <br /> io <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. c9l FORK P <br /> MARK ONLY NEW PERMIT r-j 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 1:1 7 PERMANENTLY K <br /> ONE ITEM 2 INTERIM PERMIT F-]4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 0 8 TANK REMOVE o j <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED .�'D t FARM TANK-YES 0 NO , <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: <br /> II. TANK C LATENTS 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 Bj?_1 <br /> C. ell' <br /> J ' UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT �4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS 80 EMPTY ❑ 95 UNKNOWN 2 WASTE El 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.# 4J <br /> C.A.S.#: <br /> x111. TANK CONSTRUCTION MARK ONE IT M ONLY IN BOX A,B,C,&D <br /> A.TYPE OF b2'SINGLE <br /> DOUBLE WALLED F-]3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM WALLED 4 SECONDARY CONTAINMENT [j 99 OTHER <br /> 1 STEEL/IRON E]2 STAINLESS STEEL F-�3 FIBERGLASS F-]4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK F--1 5 CONCRETE 6 POLYVINYL CHLORIDE F-�7 ALUMINUM F-]8 100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> El 9 BRONZE 10 GALVANIZED STEEL [:]95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED El 2 ALKYD LINING ❑3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR 5 GLASS LINING 6 UNLINED <br /> LINING 95 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES [-] NO E]99 OTHER <br /> D.CORROSION ❑1 POLYETHLENE WRAP 2 TAR OR ASPHALT ❑3 VINYL WRAP El <br /> 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 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 AU02 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B.CONSTRUCTION U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH 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 <br /> C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U UNKNOWN A U 99 OTHER <br /> i <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P 1 VISUAL CHECK /P/5 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> L/ <br /> S PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE- P S 95 UNKNOWN P S 99 OTHER <br /> / I. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DAT ST USED(MO/YR) 2. ESTIM�ATTFD UANTITY OF 3.WAS TA K ILLED WITH <br /> B <br /> j SUP/JAINING IN INE A AL? YES NO <br /> GALLONS <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY O PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> 1 APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> j LOCAL AGENCY USE ONLY <br /> EPERMITNUMBER <br /> JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> EI I I I o lo F/ 16 1 -2—IT ® � U <br /> WOCALEN¢Y F ILITY ID# APPRO E BY N ME PHONE#WITH AREA CODE <br /> PE AP O LDA PERMIT EXPIRATION DATE <br /> -f-PERMIT AMOUNT SURCHAR A FEE CODE RECEIPT# BY: <br /> FORM B(3-7-88) THIS FORM MUST BE ACCOMPAN A FACILITY/SITE APPLICATION, FORM'A',UNLESS RRRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />