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STATES OF CA LIFORNP 1 WATER RESOURCES CONTRA"" BOARD ••�'..::, <br /> FORM B': UN6eRGROUND STORAGE TANK PRb;�RAM <br /> TANK 'TANK PERMIT APPLICATION! INFORMATION m <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING VORMATION FOR EACH TANK. <br /> IC <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT HANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TAN <br /> f ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT e6rTEMPORARY TANK CLOSURE Qom"'"K REMOVED O <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: al <br /> o& c - ` FARM TANK-YES❑ NO <br /> W <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: ,t <br /> P <br /> 11. TANK 9RNTENTS IF(A-1),IS MARKED,COMPLETE ITEM C.IF(A.1 IS NOT MARKED,COMPLETE ITEM <br /> A. r140TOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL <br /> CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT ❑4 GASAHOL.- ❑5 JET FUEL ❑,6 AVIATION GAS <br /> ❑5 HAZARDOUS ❑80 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.# C.A.S.#: <br /> I11. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF� ❑ 1 ��LE WAD ❑3 SINGLE WALLED WITH EXTERIOfl LINER [Boom UNKNOWN <br /> SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER <br /> ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 MR CLADW/,RBERGLASSREINFORCED PLASTIC <br /> B UATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP <br /> ❑9 BRONZE ❑10 GALVANIZED STEEL �5 UNKNOWN ❑99 OTHER <br /> C. INTERIOR <br /> ❑ 1 RUBBER LINED ❑2 ALKYD LINING F-13 EPDXY LINING ❑4 P OUC UNING <br /> LINING ❑5 GLASS LINING E]6 UNLINED 5 UNKNOWN <br /> ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO E24 OTHER_ <br /> D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT V95 <br /> WRAP ❑4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑5 CATHODIC PROTECTION [:]91 NONE KNOWN I ❑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 5 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 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 /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A 995 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLEP FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> ��l�IALHECK P S 2�INVENT �REN ILIATION �PS VADOSE WELLS P �4EULE TRONIC MONITOR �S59GO�ROND ATER MONITORING WELLS <br /> N TESTINGP S 7 NONE P NOWN <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? [:]YES ❑ NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> L61010114 <br /> CURB CAL AGENCY FACILITY 10 0 APPROVED BY NAME PHONE#WITH AREA CODE <br /> a- <br /> PEARZIT NUMBER PERMIT APPROVAL DATE Rk11T EXPIRATION DATE <br /> CHECK F PERR9T AUOUNT SURCHARGE ALIT. FEE CODERECEIPT t BY: <br /> FORM B LB-29-e6) THIS FORM GUST BE ACCOMPANIED Y A FACILITY/SITE APPLICATION, FORM`A',UNLESS A RRENT FORkI'A' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />