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STATE OF CALIFORN'4 WATER RESOURCES CONTP` BOARD FORM 'B': UNIIERGROUND STORAGE TANK PRtTGRAM TANKTANK PERMIT APPLICATION INFORMATION ANk. ° b Z A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH Tl-t'tkANk. 10 MARK ONLY 2f I NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑8 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED eJ cn FACILITY/SITE NAME WHERE TANK IS INSTALLED:;?F]O i S S40C KTO,4 FARM TANK-VES❑ NO M N 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ION B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),18 MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. A. Ijj ' MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ d OIL �1 PRODUCT ❑ /OASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL 99 OTHER(DESCRIBE IN REM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.N C.A.S.W 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOIL A,B,C,A D A TYPE OF ❑ I OOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLEWALLED ❑A SECONDARYOOMAINMENT ❑99 OTHER ❑ 1 STEELIIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑d STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑5 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑S 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I AMBER LINED ❑ 2 ALKYD LINING ❑3 EPDXY LINING ❑A PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑8 UNLINED ❑95 UNKNOWN ❑ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 WNYL WRAP ❑/FIBERGLASS REINFORCED FUSTIC PROTECTION ❑5 CATHODIC PROTECTION ❑9I NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U I 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 U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U O FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEELCLAOW/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 8 FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 d ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 V.PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P O 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 R JURISDICTION N AGENCY* FACILITY ID M TANK ID B CURRENT LOCAL AGENCY FACILITY ID• APPROVED BY NAME PHONE F WITH AREA COON EYLl2 PERMITN MBER PERMIT APPROVAL DATE PERM IT EKPIRATION DATE ZI fG11 CHECK 9 PlRMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT 8 BY: 3 t FORM 8I 29-B8) THIS FORM MUST BE ACCOMPANm-dY A FACILITY/SITE APPLICATION, FORM 'A',UNLESSm4RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY