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STATE OF CALIFORNII WATER RESOURCES CONTRO' BOARD "` FORM 'B': UNDERGROUND STORAGE TANK PROGRAM �� a' TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. /` MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEDTANK ONE ITEM 1-12 INTERIM PERMIT ❑ 4 AMENDED PERMIT [:]6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: — �� FARM TANK-VES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# R. MANUFACTURED BY: C. YEAR INSTALLED 7 1 D. TANK CAPACITY IN GALLONS: II. TANK CP44TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. i MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. ❑ 1 UNLEADED ❑ 2 LEADED IESEL ❑ 3 CHEMICAL B.PRODUCT ❑ 4 OIL PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLYIN BOXA,B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM P-2-SINGLE WALLED ❑4 SEOONDARYCONTAINMENT ❑99 OTHER LIIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLADW/FlBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑81W%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑W OTHER ❑ C. INTERIOR 1 RUBBER LINE ❑2 ALKYD LINING F-13 EPDXY LINING F-]4 PHENOLIC LINING LINING ❑ 5 GLASS UNING UNLINED ❑ 95 UNKNOWN IL ❑ ISUNING MATERIAL COMPATIBLE WITH 10096 METHANOL? ❑YES ❑ NO P�r'99 OTHER IJ n D. CORROSION I PROTECTION ❑ 5 CATHODICCPPROTECTION EWRAP ❑91TNONE ASPHALT ❑95 UNYL WRAPKNOWN 99 OTHER SB REINFORCED PLASTIC IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U / SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A CV5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM AIy fiCONE A U 75TEEL CLAD W/FAP A U 81W96 METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A �(V�.^5 UNKNOWCRETN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. rl-'� P 1 VISUAL CHECK P 2 INVENTOR/RECONCILIATION P S 3 VADOSE WELLS P 5 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS P 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 3l I / sdz CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NA E PHONE#WITH AREA CODE A�IU0�646 / /o PERMIT NUMBER PERMIT APPROVAL DATE PER EXPIRATIO)FD TE JCHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: a(s-z9-ee) THIS FORM MUST BE ACCOMPANIEB'of A FACILITY/SITE APPLICATION, FORM 'A',UNLESS AL'11I9RENT FORMA' HAS BEEN FILED PATI# PROCESSING COPY