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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ _ z MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK I O ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE gf8 TANK REMOVED O FACILITY/SITE NAME WHERE TANK IS INSTALLED: ^� // � N c�� S I 1)10 VC W FARM TANK-YES NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID a S. MANUFACTURED BY: uk�j —4 G YEAR INSTALLED PrigD. TANK CAPACITY IN GALLONS. 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A 1 MOTOR VEHICLE FUEL F-1 2 PETROLEUM D. C. jj?,1 UNLEADED ❑2 LEADED ❑3 DIESEL 3 CHEMICAL PRODUCT ❑4 OIL PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GASB i ❑5 HAZARDOUS ❑80 EMPTY E]95 95 UNKNO ❑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.a C.A.S.a: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BO%A,B,C,&D A.TYPE OF ❑ 1 DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ;;af, STEEUIRON ❑2 STAINLESS STEEL ❑3FIBERGLASS ❑4STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ MATERIAL 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑B 10D%METHANOL COMPATIBLE FRP ❑9 BONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN \❑99 OTHER C. INTERIOR F-11 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED 95 UNKNOWN / ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? E]YES E]NO 16 90THER D. CORROSION ❑ 1 POLYETHLENE WRAP J<�2 TAR OR ASPHALT ❑ 3 VINYL WRAP F-14 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 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE AU 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM A6CONCRETE A U 7STEEL CLAD W/FRP A U B /DO%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 5 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. P 8 / VISUAL CHECK P 8 2 INVENTORY RECONCILIATION S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING 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 OFGALLONS S.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES E] 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY a JURISDICTION a AGENCY a FACILITY ID a TANK ID a d2 CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE IN S PERMIT NUMBER PERMIT APPROVAL DATE PE MITE (RATION DATE CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTN BY: \Vy FoRM B(6-29-88) THIS FORM MUST BE ACCOMPANI[U BY A FACILITY/SITE APPLICATION, FORM 'A',UNLEE 'URRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY iVOW -