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iTATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM PLETE .,� TANK TANK PERMIT APPLICATION INFORMATION COMA SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED I FACILITY/SITE NAME WHERE TANK IS INSTALLED: I L FARM TANK-VES❑ NO ® z 10 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# N B. MANUFACTURED BY: UN C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: �J OO W 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. W A. F-1 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED [j3 DIESEL F-13 CHEMICAL PRODUCT 4 OIL ❑ 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL El 6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN /ASTE ❑7 METHANOL OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: (J,(A-, HAZARDOUS SUBSTANCE STORED&C.A.S.# .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,A D A.TYPE OF ❑ 1 DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑6100%METHANOL COMPATIBLE ERP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER ❑1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PH LINING C LINING INTERIOR F-15 GASS LINING ❑6 UNLINED UNKNOWN F-1ISLINING MATERIAL COMPATIBLE WITH IDD%METHANOL? ❑YES NO 99 OTHER D. CORROSION ❑1 POLYETHLENEWMP ❑ 2 TAAORASPHALT ❑3 V1 P ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE D4UNKNOWN ❑99 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 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYLGHLORIDE(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 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A V 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. n P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S S GROUNDWATER MONITORING WELLS 106^ P S S PRECISION TESTING P S 7 PRESSURE TESTING P 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 7 SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ NO ,V THIS FORM H S 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# JURISDICTION# AGENCY# FACILITY ID# TANK ID# ov 3 � v D CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY ANE 00 PHONE#WITH AREA CODE U( PERMIT NUMBER PERMITAPP V D P MITEXPIRATI DATE CHECK# PERMIT AMOUNT SURCHARGE AM . FEE CODE 'RECEIPT BY: I FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RRENT FORM W HAS BEEN FILED 7 S DATA PROCESSING COPY