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f UP CALIFORNIA :. <br /> FORM 'B': MATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. } a <br /> MARK ONLY ❑ 1 NEW PERMIT <br /> ONE ITEM 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a <br /> 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 7 P ANENTLY CLOSED TANK I O <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: 6 TEMPORARY TANK CLOSURE <br /> TANK REMOVED <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY FARM TANK-YES <br /> A. OWNERS TANK ID k NO <br /> C.J <br /> L..a. <br /> C. YEAR INSTALLED B. MANUFACTURED BY: J <br /> CD <br /> II. TANK D. TANK CAPACITY IN GALLONS: <br /> TENTS IF;(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> i <br /> A. 1 MOTOR VEHICLE FUEL 0 2 PETROLEUM <br /> B. <br /> 3 CHEMICAL PRODUCT C. ❑ i UNLEADED E]2 LEADED <br /> E]4 OIL IESEL ! <br /> 5 HAZARDOUS 0 80 EMPTY []95 UNKNOWN 1 PRODUCT 4 GASAHOL 0 5 JET FUEL <br /> 6 AVIATION GAS <br /> 2 WASTE 7 METHANOL E]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 'A <br /> Zw <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D C.A.S.#: <br /> 1 <br /> A TYPE OF ❑ LLED Ej 3 SINGLE WALLED WITH EXTERIOR LINER <br /> SYSTEM1:195 UNKNOWN <br /> Ste' ALLED E]4 SECONDARY CONTAINMENT 0 99 OTHER <br /> B.TANK <br /> 1 STEEUIRON E]2 STAINLESS STEEL 3 FIBERGLASS 0 4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE 7 ALUMINUM ❑6 100%METHANOL COMPATIBLE FRA <br /> 9 BRONZE 10 GALVANIZED'STEEL E]95 UNKNOWN 99 OTHER <br /> C.INTERIOR 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> LININS ❑5 GLASS LINING 6 UNLINEDff;ANKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? El YES E:]NO ❑ 99 OTHER f <br /> D.CORROSION ❑ I POLYETHLENEWRAP Ej 2 1,AMR ASPHALT [-�3 VINYL WRAP [:]4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION [] 5 CATHODIC PROTECTION N91 NONE El.95 UNKNOWN El 99 OTHER I <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE ! <br /> A.SYSTEM TYPE U A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER• j <br /> B.CONSTRUCTION A U IN D A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER I` <br /> I S EEL/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 STEELCLADW/FRP A U 8 100%METHANOLCOMPATIBLEFRP <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 BE CIRCLED. <br /> P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S E WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING'P S 7 PAESSURE TESTING S 91 N E P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> 1.ESTIMATED DATE LAST USED(MO/YR) SUBSTANCE REMAINING IN INERT MATERIAL? YES E 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 /> oarE <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> COUTNTY k JURISDICTION.k- / <br /> AGENCY k FACILITY ID k TANK ID k <br /> 7 Lo {1 <br /> 1s APPROVED BY NAME PHONE N WITH AREA L-CODE <br /> 311 <br /> CURRENT LOCAL AGENCY FACILITY ID N <br /> I <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK N PERMIT AMOUNT RCHARGE AMT. <br /> FEE CODE RECEIPT N BY: <br /> 1/1 <br /> FORM`A',UNLESS A CORRENT FORMA HAS BEER FILED <br /> FORM B(6-29-SB) THIS FORM MUST BE ACCOMPANIEL,,,,,.FACILITYISI API PROCESSING COPY -- �� <br />