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STATE OF CALIFOUft WATER RESOURCES CONT ARD FORM `B': UNDE GROUND STORAGE TANK PR GRAM o TANK TANK PERMIT APPLICATION INFORMATION ' COMPLETE A SEPARATE FORM WITH THE FOLLOWIMG,INFnRMATION FOR EACH TANK. ",.o71 a`�' MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT MANGE OF INFORMATIONE�TtNKREMOIVED ENTLY CLO NK ONE ITEM ED 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE FACILITY/SITE NAME WHERE TANK IS INSTALLED: VV f�L S FARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS IF UNKNOWN—SO SPECIFY A. OWNERS TANK ION 5 1 B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: IL TANK G NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A, 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMVl C. ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL 3 CHEMICAL PRODUCT F—] 4 OIL RODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ BO 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.k C.A.S.N: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,&D A.TYPE OF ❑ DOUBLE WALLED F—] 3 SINGLE WALLED WITH EXTERIOR LINER E]95 UNKNOWN SYSTEM I� I `SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER F—] 1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING F__] 5 GLASSUNING F—]6 UNLINED V95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TAR ORASPHALT ❑ 3 VLWRAP ❑4 FlBEAGLASSREINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 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 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 &NGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEOTRENCH A U 91 NONE A 95 UNKNOWN A U 99 OTHER A U 1 STEELIIRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 5 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. - f P 5 1 VISUAL OHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORYNG WELLS ��vl S 8 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 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 REST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 3 V l � 610 = CURRENT LOCAL CY FACILITY ID k APPROVED BY N E PHONE k WITH AREA CODE z All 'FORMB(B-29-8s) UMBER PERMIT APPROVAL PATE RMIT EXPIRA ION DATE PERMIT AMOUNT SURCHARGE AMT. ODE 4REC.1IPT k BY: THIS FORM MUST BE ACCOMPANI A FACILITY/SITE APPLICATION, FORM `A',UNLENT FORM`A' HAS BEEN FILED DATA PROCESSING COPY