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STATE OF CALIFORNI WATER RESOURCES CONTRC OARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWINP INFORMATION FOR EACH TANK. Qp z 10 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT Yr5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED W FACILITY/SITE NAME WHERE TANK IS INSTALLED: W. — FARM TANK-VES❑ NO W 1. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY (� A. OWNERSTANKIDN Vk I B. MANUFACTURED BY: Or- C. C. YEAR INSTALLED U r-_ D. TANK CAPACITY IN GALLONS: II. TANK PONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL F] B.3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS j ❑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.R C.A.S.N. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&O A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM �INGLE WANED ❑/SECONDARY CONTAINMENT ❑99 OTHER 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8189%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR F-1i RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING D'>UNLINED ❑95 UNKNOWN � ❑ )SEINING MATERIAL COMPATIBLE WITH IM%METHANOL4 ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYETHLBIE WRAP ❑ 2T OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 1 NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE 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 B.CONSTRUCTION1 SINGLE WALLED A U 2 DOUBLEWALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 5 1 VISUAL CHECK P i t INVENTORY RECONCILIATION P 8 3 VAOOSE WELLS P S O ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS ,nl'-1 D 8 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE D 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 I 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION k AGENCY M FACILITY ID R TANK ID B E= I I I I / CURRENT LOCAL AGENCY FACILITY ID 8 APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK N PERM IT AMOUNT SURCHARGE AMT. FEE CODE gECEIPTk BY: FORM B(6-2988) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESS=")-.'; CCPv 4