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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM =` P TANK TANK PERMIT APPLICATION INFORMATION ° COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT F—] 3 RENEWAL PERMIT E] 5 CHANGE OF INFORMATION El7 PERMANENTLY CLOSED 0� ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVED "! w FACILITY/SITE NAME WHERE TANK IS INSTALLED: ' N, o-V Zf� FARM TANK-VES❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY N CT1 A. OWNERS TA NK ID# B. MANUFACTURED BY: 'J C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 1j O6 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. F-1 I MOTOR VEHICLE B. 2 LEADED 3 DIESEL A ❑3 CHEMICAL PRODUCT FUEL ❑ 4 OIL ROLEUM ^ ODUCT C ❑ 4 GASAHOLD ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 EMPTY [:]95 UNKNOWN L❑T2 rWASTE ❑ 7 METHANOL 2199 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAMEOF_30 T HAZARDOUS SUBSTANCE STORED&C.A.S.# k/f" 7;1 C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,&D UBUE LLED F--] 3 SINGLE EO TH 95 A.TYPE OF E:l SYSTEM 2 SNGLE WALLED ❑ 4 SECONDARYLCONTIA CONTAINMENT EXTERIOR LINER ❑❑ 99 OTHER I STEEURON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. MATERIAL TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE F] 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP E:19 BRONZE E] 10 GALVANIZED STEEL L] 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY UNING ❑4 PHENOUC LINING LINING ❑5 GLASS LINING 6 UNUNED ❑95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO OTHER gAdbdl2_ D. CORROSION ❑ I POLYETHLENEWRAP ✓❑f2 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(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 m 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 UNEDTRENCH A U 91 NONE A U 95 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 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 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. uYI17D P B IVISUALCHECK P 8 2 INVENTORY RECONCILIATION 3VADOSEWELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS ,Vv P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIM TED DATE LAST USED(MOYYR) 2. ESTIMATED QUANTITY OF 3.WASTAN FILLED WITH / SUBSTANCOEMAINING IN INE M IAL? [—]YES ❑ NO K/ GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLED E,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE A-IL- PERMIT NUMBER PERMIT APPROVAL D PERMIT EXPIRATION DATE CHEM# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT BY: FORM B(6-29-89) THIS FORM MUST BE ACCOMPANI"Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS RBEORM'A' HAS BEEN FILED /