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STATE OF CALIFOFWIA WATER RESOURCES COOL BOARD FORM 'B': U ERGROUND STORAGE TANK OGRAM � m= TANK TANK PERMIT APPLICATION INFORMATION -® COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z f !O MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED /T FACILITY/SITE NAME WHERE TANK IS INSTALLED: ywo m/;' & FARM TANK-YES❑ NO V (a I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY ~ A. OWNERS TANK ON B. MANUFACTURED BY: afi�- N C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: c oo I II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY 5 UNKNOWN 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# aff-- C.A.S.R: ✓((Z III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A.TYPE OF ❑ I DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED 4 SECONDARY CONTAINMENT ❑99 OTHER F-11 STEEL/IRON ❑2 STAINLESS STEEL F--13 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK - ❑ MATERIAL 5 CONCRETE 6 POLYVINYLCHLORIDE ❑ 7 AL E]B 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER C. INTERIOR F-11 RUBBERLINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHEN ING LINING F-15 GLASS LINING F-16 UNUNEO 5 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL9 ❑YES ❑NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHLENEWRAP ❑ 2 TAR OR ASPHALT ❑3 V PAP ❑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 U 2 PRESSURE A U 3 GRAVITY A U 91 NONEU U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE C U 95 UNKNOWN AD 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 U A U7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 95 UNK OW 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 I VISUALCHECK P S 2 INVENTORY RECONCILIATION P3 VADOSE WELLS P 8 4 NIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING S 95 N OWN 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 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION N AGENCY# FACILITY ID# TANK ID# EEI I 15-EKE] D � � CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE N WITH AREA CODE 1 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE \r�) f CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: U� FORMB(6-29-88)(6-29-36) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A A'CURRENT FORMHAS BEEN FILE v DATA PROCESSING COPY