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STATE OF CALIFORNI& WATER RESOURCES CONTRX0 0ARD ;. FORM 'B': UND - - ROUND STORAGE TANK PR AM ; an< TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK, MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT �5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED OlIry FACILITY/BITE NAME WHERE TANK IS INSTALLED: I E VF s-rzd gSzoZ FARM TANK-YES❑ u t/NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY Ip A. OWNERS TANK ID F vill r- B. MANUFACTURED BY: V N K• W C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: (Q ,v v v 6-,4(- II. -,4(- 11. TANK CONTENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(At),IS NOT MARKED,COMPLETE ITEM D. CST A. ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ i UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 1 OIL ❑ 1 PRODUCT ❑ 0 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS [?t-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 S C.A.S.R C.A.S.B: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM �2 SINGLE WALLED ❑ 1 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEELIIRON ❑2 STAINLESSSTEEL ❑3 FIBERGLASS ❑/STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL ❑5 CONCRETE ❑6 POLYWNYLCHLORIDE ❑ 7 ALUMINUM ❑ B 10D%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL Ea'5 UNKNOWN ❑99 OTHER Q INTERIOR ❑ I RU88ERUNED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑/PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED Q95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO 99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑X FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE &J-95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A LA I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A ZrO5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U / FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A' U 7 STEEL CUD WEEP A U 8 109%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. ,L•L�J P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S A ELECTRONIC MONITOR P 8 5 GROUND WA MONITORING WELLS r/ P 8 6 PRECISION TES TING 8 ]PRESSURE TES TING P 8 91 NONE P 6 95 UNKNOWN P 99 OTHER. L' VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) Z. ESTIMATED QUANTITY 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 A SIGNATURE) DATE 1 LOCAL AGENCY USE ONLY COUNTY B JURISDICTION 8 AGENCY 8 FACILITY ID 0 TANK ID k 10101 I I I Oil IU I O I D CURRENT LOCAL AGENCY FACILITY 101 APPROVED BY NAME PHONE•WITH AREA CODE 5 (4,4-,6- 6o E PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT I BY: fir. FORM a(6-29-ee) THIS FORM MUST BE ACCOMPANIED B1 . CILITYISITE APPLICATION, FORM 'A',UNLESS A CU hn_ T FORMA' HAS BEEN FILED DATA PROCESSINY: CODv