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STATE OF CALIFORNI` WATEA' RiSOURCES CONTRO" ZOARD <br /> FORM `B': UNDEMGROUND STORAGE TANK PROITRAM <br /> TANK TANK PERMIT APPLICATION INFORMATION ® ' <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 PERMANENTLY CLQSED-TAI K <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED,' f f r { <br /> i' <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: + '! �; !+ f O. i; FARM TANK-YES❑ NO ' <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-fIF UNKNOWN—SO SPECIFY F �� <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: <br /> C. YEAR INSTALLED .;` D. TANK CAPACITY IN GALLONS: s'R <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. <br /> A- 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B- C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL <br /> ❑3 CHEMICAL PRODUCT 4 OIL ❑ 1 PRODUCT ❑4 GASAHOL 0,5 JET FUEL ❑6 AVIATION GAS <br /> ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL M 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# (} I { C.A.S.#: L2 L- <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,6 D <br /> A.TYPE OF ❑/6OUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER <br /> 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC <br /> B.TANK <br /> MATERIAL ❑5 CONCRETE 6 POLYVINYLCHLORIDE 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP <br /> ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER <br /> C. INTERIOR F-11 RUBBER LINED 2 ALKYD LINING F-] ❑3 EPDXY LINING 4 PHENOLIC LINING <br /> LINING ❑5 GLASS UNING ❑6 UNLINED ❑` 95 UNKNOWN <br /> ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑ NO ❑ 99 OTHER <br /> D.CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TARORASPHALT 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 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 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 FI ERGLASS PIPE A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLADW/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 S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURETESTING 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 /> L I SUBSTANCE REMAINING IN <br /> IN MATERIAL? F7]YES ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> Ll L 1 1 -1 Fi F 1 di, I El I d <br /> `AGENCY FggACILITY IDM APPROVED BY NAME• PHONE M WITH AREA CODE <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION D¢YE <br /> PERMIT AMOUNT SURCHARGE AMT. FEE CODE +9ECEIPT it BY: <br /> r <br /> PHIS FORM MUST BE ACCOMPANId5BYA FACILITY/SITE APPLICATION, FORM 'A',UNLESS URRENT FORMA' HAS BEEN FILED <br /> FILE COPY <br />