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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM ' TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. :: MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED oq FACILITY/SITE NAME WHERE TANK IS INSTALLED: � FARM TANK-VES❑ NO Z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY IG A. OWNERS TANK ID N TVG B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: W 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. N A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUMB. C. ❑ 1 UNLEADED ❑2 LEADED DIESEL F-13 CHEMICAL PRODUCT ❑4 OIL PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS i ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C A.S.# C.A.S.#: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,8,C,8 D A TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM g1 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER 4EELARON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL GAD W/RBERGIASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8108%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 13 GALVANIZED STEEL ❑95 UNKNOWN ❑%OTHER F-11 RUBBER LINED ❑2 ALKYD LINING F-13 EPDXY LINING ❑ 4 PHENOLIC UNING C. INTERIOR LINING F-15 GLASS LINING �E UNLINED ❑ 95 UNKNOWN ❑ISUNING MATERIALCOMPATIBLEWITH IOD%METNANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ I POLYETIALENE WRAP ❑2 T_ARORASPHALT ❑3 VINYL WRAP ❑/FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION EB-9-114DNE ❑%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 99 OTHER B.CONSTRUCTION A SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(WC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 1 OD%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER NV. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. o--p S 1 VISUAL CHECK P S 2 INVENTORY RE CONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 1 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# LTJ 16101113 CURRENT LOCAL AGENCY FACILITY ID# APPR D BY NAME PHONE#WITH AREA CODE (! IPERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE W1' [MHECK# PERMIT AMOUNT SURCHARGE ANT. FEECODE RECEIPT# BY: FORM B 13-7-Rel THIS FORM MUST BE ACCOMPA Y A FACILITY/SITE APPLICATION, FORM 'A',UNLES RENT FORM'A' NAS BEEN FILED DATA PROCESSING COPY