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STATE OF CALIFORN& WATER RESOURCES CONTFOBOARD FORM B': UNDERGROUND STORAGE TANK PR GRAM .. 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 PER NENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-VES❑ NO 77 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY IC/ A. OWNERSTANKIDR B. MANUFACTURED BY: N 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. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM R. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT F-14 OIL F-11 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 L HAZARDOUS SUBSTANCE STORED&C.A.S.R C.A.S.R: S All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ I DO WALLED ❑ 3 SINGLEWALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM Lalr2 SINGLE ALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER D-TIM' BUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL GLAD W/RBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE E]6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ C. INTERIOR 1 RUBBBTUN87 E] 2 A WING ❑ 3 EPDXY LINING ❑ 4PHENOUC UNING LINING ❑5 GLASS LINING UNLINED ❑95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLEWITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ i POIYETHLENE W(TAP ❑ 2 TA 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 99 OTHER A B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A @�>OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD 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 S- 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS IL P S)6 PRECISION TESTING P 3 7 PRESSURETESTING P S 91 NONE- P S 95 UNKNOWN P S 99 OTHER '#Y VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED MP/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 K JURISDICTION a AGENCY N FACILITY ID R TANK ID R 1010 1 1 p o lo CURRENT LOCAL AGENCY _ / APPROVED BY MANE P k WITH AREA CODE PERMIT NUMBER 6r/ PERMIT APPROVAL DATE PERMIT EVIRATION DATE CHECK X PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: FORMB(3-7-88) THIS FORM MUST BE ACCOMPAN IED FACILITY/SITE APPLICATION, FORM'A',UNLEIWWNT FORMA' HAS BEEN FILED DATA PROCESSING COPY 4-