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kFORM 'B': OF CALIFORN* WATER RESOURCES CONTROOARD _ UNDERGROUND STORAGE TANK PROGRAMK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ONLY ❑ I NEW PERMIT ❑ 3 RENEWALPERMIT 1 5 CHANGE OFINFORMATION ❑7 PERMANENTLYCLOSED TANKTEM ❑2INTERIM PERMIT ❑ 44l AMENDEDPERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED /SITE NAME WHERE TANK IS INSTALLED: OA �Q� aC ' � FARMTANK-VES❑ NO ESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFYS TANK ID# (� B. MANUFACTURED BY:NSTALLED D. TANK CAPACITY IN GALLONS: Q Q W IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. I V A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ i UNLEADED 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL 21111'PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑ BO 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.#: MI. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑,�, 1/O�OUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM I l Y2 SINGLEWALLED ❑4 SECONDARYCONTAINMENT ❑99 OTHER `V STEELARON ❑2 STAINLESS STEEL ❑3FIBERGLASS ❑4STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL F-] 5 CONCRETE E]6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑ B 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBERLNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR 5 GLASS [O<UNLINED ❑95 UNKNOWN LINING ❑ ❑ ISLINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENEWRAP 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 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 U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A W 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FISERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A(9 95 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 3 1 VISUAL CHECK 10 S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 3 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE' P 8 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 F,,ILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? DYES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 3 aI In 101 10 1 d 0 CURRENT LOCAL ADENCYFACILITY ID# APPROVED By NAME PHONE#WITH AREA CODE / AC 7 IS 8t (�/ PERMIT NU BEP PERMIT APPROVAL DA PERMIT EXPIRATION DATE u CHECK# PERMIT AMOUNT SURCHARGE ANT. FEE CODE RECEIPT BY: ! FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIED 6,H FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CANT FORMA' HAS BEEN FILED DATA PROCESSING COPY `'