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STATE OF CALIFORNIA WATER RESOURCES CONTR(" BOARD FORM 'B': UNDETIGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING FORMATION FOR EACH TANK. - MARK ONLY ❑ I NEWPERMIT ❑3 RENEWALPERMIT 315CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED zFACILITY/SITE NAME WHERE TANK IS INSTALLED: 2 DLe 1 FARM TANK-VES NO ❑ •0 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# dq B. MANUFACTURED BY: L4 C. YEAR INSTALLED /c ID. TANK CAPACITY IN GALLONS: a & D I"► II. TANK CONTENTS IF(A.1),18 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETEJTEM D. MOTOR CLE A F-1 3 CHEMICAL PIRODUCTL ❑ 4 OIOLEUM B 1 PRODUCT C UNLEADED❑4 GASAHOL ❑5 JET FUEL E]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 8 C.A.S.# C.A.S.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,0,C,&D A.TYPE OF ❑1 DOUBLEWMiED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEMSINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER STEEUIRON ❑2 STAINLESS STEEL F-13 FIBERGLASS ❑4 STEL CLAD WIFlBERGLASS REINFORCED PlA511C B. TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED MEL ❑95 UNKNOWN ❑99 OTHER F-] 1 RUBBER UNDO ❑2 AU(YDUNING F-]3 EPDXY LINING F-]4 PHENOLIC UNING C. LINING INTERIOR F-] 5 GLASS LINING ❑6 UNLINEDUNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYETILENE WRAP ❑2TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE Mf UNKNOWN ❑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 U 3 GRAVITY A U 91 NONE U 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 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A hU^' 6�CONCRETE A U 7 STEELCIAD W/RHP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A( � 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 S 1VISUALCHECK P 8 21NVENTORY RECONCILIATION P WELLS P 8 4ELECTRONIC MONITOR P 8 SGROUND WATER MONITORING WELLS P 5 6 PRECISION TE STING P S 7 PRESSURE TESTING 8 91 NONE P 6 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY I /� TANK ID# ojo00 CURRENT ENCY FACILITY IDM APPROV D BY ME PHONE M WITH AREA CODE ! D ECHECK NUMBER PERMIT APPROVAL DA PERMIT EXPIRATION DATE # PERMIT AMOUNT SURCHARGE AMT. FEE CODE Rwjipr# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIEDV"FA`,,Y/SITE APPLICATION, FORM 'A',UNLESS A CUR ENT M'A' HAS BEEN FILED DATA PROCESSING COPY