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STATE OF CALIFORNIA WATER RESOURCES CONTROL 7ARD "•w "• FORM 'B': UNDERZ;ROUND STORAGE TANK PROGRAM TANKTANK PERMIT APPLICATION INFORMATION ANK. COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TZ 10 MARK ONLY NEW PERMIT F-13 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT E] 6 TEMPORARY TANK CLOSURE TANK REMOVED N FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-VES❑ NO JW -8111, I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY w A. OWNERS TANK ID M — 1 B. MANUFACTURED BY: I C4 C. YEAR INSTALLED ` D. TANK CAPACITY IN GALLONSZ 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 ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT �4 OIL 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.M L- C.A.S.9: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXA,B,C,tD A.TYPE OF ❑ 1 DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM X2 SINGLE WAILED ❑4 SECONDARY CONTAINMENT ❑99 OTHER YTS ' STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 1 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED 2 ALKYOUNING r73 EPDXY LINING F—]4 PHENOLIC LINING E]LINING 5 GLASS UNING Y�;UNLINED ❑ 95 UNKNOWN [:]ISLINING MATERIAL COMPATIBLE WITH IW%METHANOL? —]YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP X2 TAR OR ASPHALT ❑ 3 VINYL 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 UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A 1 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 A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%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 8 FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S IVISUALCHECK P S 2 INVENTORY RECONCILIATION P 8 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 5 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 8 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 GALLONSINERT 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 A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION M AGENCY M FACILITY ID A TANK ID M ® = = 10110 1 I ]= 10 1(0 1 '2, 15 CURRENT LOCAL AGENCY FACILITY IDM APPR D ME PHONE M WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT FORM DIS-29-ee) THIS FORM MUST BE ACCOMPANIE�MIYA FACILITY/SITE APPLICATION, FORM 'A',UNLESS A-CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY