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STATE OF CALIFORN& WATER RESOURCES CONTRNBOARD FORM 'B': UNDERGROUND STORAGE TANK PR RAM TANK TANK PERMIT APPLICATION INFORMATION m ry COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 0 10 MARK ONLY ❑ 1 NEWPERMIT ❑3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE YANK REMOVED 0 FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-VES❑ NO j! I. 'TANK DESCRIPTION COMPLETE ALL ITEMS IF UNKNOWN–SECIFY TAN N A. OWNERS K ID# Zj B. MANUFACTURED BY: C.YEAR INSTALLED ID. TANK CAPACITY IN GALLONS: V 11. TANIC.CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑2 ETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT V4 OIL PRODUCT ❑4 GASAHOL ❑ 5 1 UEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN WASTE ❑7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAMEOF 1 HAZARDOUS SUBSTANCE STORED&C.A.S.# IV C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ DOUBLEWALLED F73 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM W 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER �1 STEELPRON ❑2 STAINLESS STEEL F73 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8100%METHANOL F./OMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN 99 OTHER C.INTERIOR F-11 RUBBERUNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC UNING LINING ❑5 GLASS LINING 6 UNLINED ❑95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TARORASPHALT ❑3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDE OUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U SUCTION A U 2 PRESSURE A U GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH 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 A6 CONCRETE A U 7 STEEL CLAOW/FRP A U 8 100%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. �// yy'' P S 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS NO'rC P S 6 PRECISION TESTING P S 7 PRESSURE TESTING 8 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE i.ESTIMATED AT ST USED(MO/YR) 2. ESTIMATEf.PUANTITY OF 3, WAST NK FILLED WITH SUB EMAINING IN IN GALLONS TERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY dF PERJURY,AND TO THE BEST OF MY KNOWL LGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID N TANK ID# = = o0 /T? s-F-y00oFz CURRENT LOCALAO�FOACIL'TY IDN AgPppVED BYDNAM�� PHONE#WITH AREA CODE IAe PERMIT NUMBER V PERMIT APPROVAL(DATE (/ PERMIT SAPIRATION DATE CHECKN PERMIT AMOUNT SURCMAROE AMT. FEE CODE RECEIPTNBY: LL4— FORM a(6-29-86) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A HHENT FORMA' HAS BEEN FILED DATA PROCESSING COPY