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STATE OF CALIFORNI/ WATER RESOURCES CONTRC OARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY 711 NEW PERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK 10 ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: croo Fi PvA4po FARM TANK-VES❑ NO N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IFUNKNOWN-SO SPECIFY A. OWNERS TANK ID# I/• K B. MANUFACTURED BY: C/, K // ^� C. YEAR INSTALLED U k. D. TANK CAPACITY IN GALLONS. -7, 3Z 63 o II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. Z 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL 1CT ❑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.# CAS.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A. TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER %UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑%OTHER ❑ 1 STEBUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PIAS TIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 UMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL %UNKNOWN ❑99 OTHER ❑ 1 RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 ENOUCLINING C. INTERIOR 5 GLASS LINING 6 UNLINED %UNKNOWN LINING ❑ ❑ ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 AwLwRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE %UNKNOWN ❑ %OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A m95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLEWALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A<0I35 UNKNOWN A U 99 OTHER A U / STEEL/IRON A U 2 STAINLESSSTEEL 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 STEELCLADW/FRP A U S 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A<D5 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. 11 P 8 1 VISUAL CHECK P 6 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 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 USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH q- /cY/ SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? Z YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# o O z. CURRENT LOCAL AGENCY F CILITY ID N APPROVED BY NAME PHONE#WITH AREA CODE / A D� D PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CNECK# PERMITAMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: FORM B(6-29-881 THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY