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STATE OF CALIFORNI/a WATER RESOURCESCONTROJrARD FORM 'B': UNDERGROUND STORAGE TANK PRO AM N TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ 10 MARK ONLYVINTWERIM PERMIT F-] 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE K ONE ITEM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED b FACILITY/SITE NAME WHERE TANK IS INSTALLED: 5 F : (�/L /�( FARM TANK-VES❑ NO .pb I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY N u Ca O I, A. OWNERS TA NK ID# 1/ B. MANUFACTURED BY: S W G YEAR INSTALLED 1 D. TANK CAPACITY IN GALLONS: VUV 11. TANK 9ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED OMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C_ 1 UNLEADED ❑ 2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT F-] 4 OIL I 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:A.S.# --'-- ----" C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM �2 S GLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER I STEELARON El STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8100%METHANOL COMPATIBLE FRP MATERIAL ❑-BBRONZE---- --"❑l0-GAE9RIZEb'STEEL 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBERUNED- ❑2 ALKYD LINING ❑ 3 EPDXY LINING 4NOUC LINING LINING ❑ 5 GLASS LINING F-16 UNLINED 95 UNKNOWN �� ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? E]YES [:] NO �9 OTHER D.CORROSION ❑ I POLYETHLENEWRAP ❑2TAR OR ASPHALT ❑ VINYLWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEIII TYPE A/U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH Ml 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 A8 CONCRETE A U 7 STEEL CLAD W/FRP A U B 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 VkSNAL CHECK P 5 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS UJ S 8��'11PRECISION TESTING S ] PRE59URE TES TING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. NFORMATION 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 COUNTYY/# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 6- CURRENT LOCAL"fNCY FACILITY ID# APPROVED BY NAME PHONE M WITH AREA CODE Y I lvpsr7 2/ �41� PERMIT NUMBER PERM IT APPROVAL DATE PERMIT EXPIRATION DfrE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEECODE CEIPT# BY: FORM 8(6-29-BB) THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY