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STATE OF CALIFORNI& WATER RESOURCES CONTR OARD <�° r /5 FORM `B': UND ROUND STORAGE TANK PROI,RAM TANK TANK PERMIT APPLICATION INFORMATION ° COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. C'Otl OP MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ✓ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOV I FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK - YES I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN — SO SPECIFY IV TANK - am r A. OWNERS TANK ID # B. 1 PRODUCT 2 WASTE G✓ B. MANUFACTURED BY: VAAIC.J C. YEAR INSTALLED l ❑ 99 OTHER D. TANK CAPACITY IN GALLONS: (p 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE 1 J%Nl% L/%JIV 1 cm II 0 IF (A.l), IS MARKED, COMPLETE ITEM G. IF (A.l), IS NOT MARKED, COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM 3 CHEMICAL PRODUCT ❑ 4 OIL 5 HAZARDOUS 80 EMPTY ❑ 95 UNKNOWN B. 1 PRODUCT 2 WASTE C. ❑ 1 UNLEADED 'J;�j 2 LEADED ❑ 3 DIESEL ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS 7 METHANOL 99 OTHER (DESCRIBE IN ITEM D, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF HAZARDOUS SUBSTANCE STORED & C.A.S. #Allll�—C.A.S. #: xill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, 8, C, & D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEMSINGL WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER 99 OTHER STEEL/IRON 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. MATERIAL F-]1 RUBBER LINED ❑ 2,,A&D LINING ❑ 3 EPDXY LINING F--]4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN PERMIT AMOUNT ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAPg9l 2 OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION NONE ❑ 95 UNKNOWN ❑ 99 OTHER rIF'IIY%9 imrvnm#4I IVIY UIHL;Lt A IF AC UHUUNU, U W UNUtHUHUUINU, l3U I M It AFFLIGACLt A, SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A V5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100% METHANOL COMPATIBLE FRP �� PERMIT AMOUNT SURCHARGE AT. FEE CODE RECEIPT # A U 9 GALVANIZED STEEL APU >5 UNKNOWN A U 99 OTHER . LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 1✓� P 6 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 ZED (MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH FACILITY ID # SUBSTANCE REMAINING IN INERT MATERIAL? [1] YES ❑ NO 1 GALLONS r41Li-T� L- THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME (PRINTED & SIGNATURE) DATE 1 A[_AI A[.FAI(_Y I ICF ANI V COUNTY # JURISDICTION # AGENCY # FACILITY ID # TANK ID # ® r41Li-T� L- ��o CURRENT LOC L AGEN�C)Y FACILITY I # APPROVED BY N PHONE #WITH AREA CODE V s 3q PERMIT NUMBER PERMIT APPRODATE RMIT EXPIRATION DATE l5 `.Z CHECK # PERMIT AMOUNT SURCHARGE AT. FEE CODE RECEIPT # BY: FORM B (3-7-88) THIS FORM MUST BE ACCOMPANIEGIIY A FACILITY/SITE APPLICATION, tUMM -A-, UNLESS ATWHENT FORM -N MAS BEEN FILED DATA PROCESSING COPYy