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STATE OF CALIFORNI WATER RESOURCES CONTROARD FORM 'B': UNDEr-GROUND STORAGE TANK PRO AM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - Z 1c MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PE ANENTLY CLOSED TANK ONE ITEM F—] 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVED log rQ FACILITY/SITE NAME WHERE TANK IS INSTALLED: F'AAVE FARM TANK-VES❑ NO ❑ ,A uJ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY (V A. OWNERS TANK ID# 7�- U 1 B. MANUFACTURED BY: kR C. YEAR INSTALLED. TANK CAPACITY IN GALLONS: C) OU[� II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS OT MARKED,r-HPL�TE ITEM D A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. F LN\\LEADED T- LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑ 4 GASAHOL U 5 JET FUEL ❑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 ,A \l HAZARDOUS SUBSTANCE STORED&C.A.S.# I�-/ A- C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a O A.TYPE OF ❑ 1 DOUG ALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN , SYSTEM NGLE ED ❑4 SEOONDARYCONTNNMENT ❑99 OTHER STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM B 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ i RUBBER UNED ❑2 AU(YD LINING ❑ 3 EPDXY LINING ❑❑4 PHENOLIC NTNG C. INTERIOR ,(—�,1! KNOWN LINING ❑5 GUSSUNING ❑6 UNLINEDKNOWN ❑ IS LINING MATERULCOMPATIBLEWITH 100%METHANOL? YES ❑NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 T 0ASPHALT ❑ 3 VNd WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION 91 NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 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 STEELMRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM A U 6CONCRETE ,A U 7STEELCLADW/FRP A U 6100%METHANOL COMPATIBLE FAP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER .i .� V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P 6 3VADOSEWELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS P S PRECISION TESTING P S 7 PRESSURETESTING P 8 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USEDq(M d// 2. ESTIMATED QUANTITY OF GALLONS 3. WAS TANK FILLED WITH /m SUBSTANCE REMAINING IN INERT MATERIAL? yES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# L GENCY FACILITY ID# APPROVED NAM PHONE#WITH AREA CODE R� a-I 9� R PERMIT APPROVAL DATE PER IT EXPIRA NDATE AL PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-66) THIS FORM MUST BE ACCOMPANm Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS ., RRENT FORM wA' HAS BEEN FILED DATA PROCESSING COPY