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STATE OF CALIFORNIA WATER RESOURCESCONTRO*ARD FORM `B': UNDER ROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 10 MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PER5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVE w FACILITY/SITE NAME WHERE TANK IS INSTALLED: Jr t Y FARM TANK-VES NO IV I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY m _1 A. OWNERSTANKID# Ot B. MANUFACTURED BY: e�11 C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: D D V II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED LEADED lz 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL E91�PROOUCT ❑ 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 C.A.S.#: HAZARDOUS SUBSTANCE STORED&C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.&D A.TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINEA ❑ 95 UNKNOWN SYSTEM L SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER [911 5TEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ B 109%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKY LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING UNLINED ❑95 UNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE W1H 100%METHANOL? El YES ❑ NO OTHER D. CORROSION ❑ I POLYETHLENEWRAP ❑ 2 TAR OR ASPHALT ❑ 3 V[:] L WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION [:] 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER r IV. PIPING INFORM ION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE 4UA SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION 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 A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A P4 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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. MIS', P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P B 7 PRESSURE TESTING S 1 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMAT D ATE LAST USED(MO/YR) 2. ESTI ATED QUANTITY OF 3.WAS TA KFILLED WITH 6 T/INCE REMAINING IN INOiT/ RIAL? ❑YES ❑ NO /V GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALYY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPUCANT'SNAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# oa 3 G o 1 CURBONT LO G7PERMIT 10# APPROV D Y AME / M _ PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIITEXPIRATIOA DATIVCHECK# OUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED aY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CUAIENT FORMA' HAS BEEN FILED DATA PROCESSING COPY