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STATE OF CALlf ORNIAll WATER RESOURCES CONTR OARD FORM 'B': UNDE GROUND STORAGE TANK PRO RAM ` m' TANK PERMIT APPLICATION JNFORMATION TANK VOMPLETE A SEPARATE FORM WITH THE FOLLOWI G INFORMATION FOR EACH TANK. — Z 14J MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C NK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 6 FACILITY/SITE NAME WHERE TANK IS INSTALLED: J FARM TANK-VES❑ N O I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SP IFY N A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ ROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT M4 OIL ❑ 1 RODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS F-180 EMPTY ❑ 95 UNKNOWN WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF14/n�L o HAZARDOUS SUBSTANCE STORED&C.A.S.# (ry'4 7t C.A.S.#: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.&D A.TYPE OF ❑ 1�OUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑ 95 UNKNOWN SYSTEM Lr-�f17/`,SINGLEWALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEL/IRON ❑2 STAINLESS STEEL ❑ 33 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC F-1B.TANK 5 CONCRETE E]6 POLYVINYLCHLORIDE n ya�UMINUM ❑ 8100%METHANOL COMPATIBLE FRP MATERIAL 'yWh/ ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER ❑ 1 RUBBER UNED ❑2 ALKYD UNING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR5 GLASS UNING ❑6 UNUNEDUNKNOWN LINING ❑ ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TAR OR ASPHALT ❑3 NYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDER GROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON'� A U 2 STAINLESSBTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A ;P4I6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A U95 UNKNOWN A U 99 OTHER V. AK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. --1 vll P 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS 1 P 6 PRECISION TESTING P 5 ] 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# CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE TF Z PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE r'z i IA11n/S,SA'1 CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE COOE RECEIPT# BY: S FORM B(6-29-80) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FO R M `A',UNLESSACUHRENT FORMA' HASBEENFILED ��YYY DATA PROCESSING COPY