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STATE OF CALIFORNII WATER RESOURCESCONTRO' IOARD FORM 'B': UNDERGROUND STORAGE TANK PROZ:RAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ i NEWPERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ©'9 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: / FARM TANK - VES C I. TANK DESCRIPTION COMPLETE ALL ITEMS -IF UNKNOWN -SO SPECIFY A. OWNERS TANK ID# B. MANUFACTUREDBY: //11 /^1 _ C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: I1 oa(/ Q II. TANK CONTENTS IT (A.1), IS MAMRCU, LUNI 1 C 11 CM 1. IT 1M.17, IJ .V' M (6 NO A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. ❑ 1 DOUBLE WALLED C. ❑ i UNLEADED 2 LEADED ❑ 3 DIESEL F-13 CHEMICAL PRODUCT ❑ 4 OIL 1 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. S. # C.A.S. W III. TANK CONSTRUCTION MARK[ wE ITEM ONLY IN BOX A, B, C, a O A. TYPE OF ❑ 1 DOUBLE WALLED ❑NGLE WALLED WITH EKTEfl10fl LINEA E:]95 UNKNOWN SYSTEM ❑ 2SINGIE WAILED ❑ 4 DARTCONTAINMENT ❑ 99 OTHER A ❑ 1 STEEL/IRON ❑ 2 STAIN SS STEEL ❑ 3 FIBERGLASS ❑ 4 SIEELCLAD WIFIBEflGIASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVI CHLORIDE ❑ 7 ALUMINUM ❑ B 100# METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANI STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A U ❑ 1 RUBBER UNED ❑ 2 ALKYD UNING❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING C. INTERIOR LINING F-]5 GLASS LINING ❑ 6 UNLINED C. MATERIAL ❑ 95 UNKNOWN 5ALUMINUM A U ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHLEIE WRAP ❑ 2TAR OR ASPHALT 3VINYLWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION E]5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UN ERGROUND, BOTH IF APPLICABLE 2. ESTIMATED OUANTITY OF3. WAS TANK FILLED WITH TANK ID R A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER CURRENT LLAOENCY FACT IDN A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U POLYVINYL CHLORIDE(PVC) A U 4 RBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM A U 6CONCRETE A U 7 EEL CLAD W/RIP A U 8100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 O ER CNECKN PERMIT AMGU NT SURCHARGEAMT. V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDA ,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S S PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 U NOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED OUANTITY OF3. WAS TANK FILLED WITH TANK ID R SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO GALL NS THIS FC RM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF KNOWLEDGE, IS TRUE AND CC APPLICANTS NAME (PRINTED 8 SIGNATURE) DATE AUCMV T VAC UDNLT ?RECT. COUNTY # JURISDICTION # AGENCY # FACILITY ID B TANK ID R = 10oa CURRENT LLAOENCY FACT IDN APPROVEY=AM PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CNECKN PERMIT AMGU NT SURCHARGEAMT. FEE CODE RECEIPT* BY: FORM B re -29-981 THIS FORM MUST BE ACCOWANIED BY A FACILITY/SITE APPLICATION. UNLESS RENT FORMA HAS BEEN FILED FORM 'A'. N CD A