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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. z <br /> 1 <br /> MARK ONLY F-11 NEW PERMIT F-] 3 RENEWAL PERMIT jq�Fr CHANGE OF INFORMATION ❑ 7 PERMANENTLY C OSEDT K 0 <br /> ONE ITEM F--12 INTERIM PERMIT E] 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED <br /> N <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: Q D eV. FARM TANK-YES <br /> ❑ NO � <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY L'1 <br /> A. OWNERS TA NK ID# -2, B. MANUFACTURED BV: VS <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: <br /> H. 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 B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL <br /> ❑3 CHEMICAL PRODUCT ®,ARIL PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS <br /> ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL �OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF A� <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: Jl <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,6 D <br /> A. TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑ 95 UNKNOWN <br /> SYSTEM Rl 2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER <br /> Q'1 STEBUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLA671C <br /> B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 ID0%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> ❑ 9 BRONZE ❑10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER <br /> C.INTERIOR ❑ 1 RUBBERLINED ❑ 2 ALKYD UNING ❑ 3 EPDXY UNING ❑4 PHENOLIC LINING <br /> LINING ❑ 5 GLASS UNING gw�fUNUNED ❑95 UNKNOWN <br /> ❑ IS LINING MATERIAL COMPATIBLE WITH 10D%METHANOL? ❑YES ❑ NO OTHER <br /> D CORROSION F-11 POLYETHLENEWRAP ❑2 TAR OR ASPHALT F-1 3 VINYL WRAP ❑4 RBERGIASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ,E 95 UNKNOWN ❑ 99 OTHER <br /> IV. PIPING INFORM ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE 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 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 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUM A6 CONCRETE A U 7 STEEL CLAD W/FRP A U S 101M METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZEDSTEEL A 95 UNKNOWN A U 99 OTHER <br /> LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P VISUAL GHECK 8 2 INVENTORY RECONCILIATION P 6 3 VADOSE WELLS P 5 4 ELECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELLS <br /> -� P 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTI A EO DATE LAST USED(MO/VR) 2. ESTIMATE QUANTITY OF 3.WAST FILLED WITH <br /> SUB A E MAINING IN GALLONS IN RT A IAL? ❑YES E] NO <br /> TH16 FORM HAS BEEN COMPLETED UNDER PENALTY PERJURY,AND TO THE BEST OF MY KNOWL GE IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> = = I o 1 b 1 t d lo 512 <br /> CURRENT LOCAL AGID# APPROVED BY PHONE#WITH AREA CODE <br /> CaCYPHONE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT PIRATION DATE <br /> CHECK# PERMIT AMOUNT SURCHARGE AMT. FEECODE RECEIPT# BY: <br /> FORM 8(6-29 as) THIS FORM MUST BE ACCOMPANIE'nY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A-MRRENT FORMA' HAS BEEN FILED <br />