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t OF CALIFOR FORM `B': WATER RESOURCES CONT UND RGROUND STORAGE TANK PRGRAM BOARD TANK TANK PERMIT APPLICATION INF COMPLETE A SEPARATE FORM WITFI THE FOLLOWING MARK ONLY Ell NEW PERMIT INFORMATION FOR EAC NATION fi TANK. ONE ITEM ❑3 RENEWAL PERMIT ❑❑ S CHANGE OF INFORMATION 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 7 PERMANENTLY CLOSED TANK FACILITY/SITE NAME WHERE TANK IS INSTALLED: ❑6 TEMPORARY TANK CLOSURE �B TANK REMOVED �• TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN FARM TANK-YES NO A. OWNERS TANK ID# ,� 50 SPECIFY 4bb C. YEAR INSTALLED B. MANUFACTURED BY: (4 ��. TANK/CONTENTS D. TANK CAPACITY INGALLONS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D� A. t MOTOR VEHICLE FUEL ❑ 2 PETROLEUM ❑3 CHEMICAL PRODUCT ❑ B C. ❑ t UNLEADED ❑ 4 OIL 2 LEADED �—�� ❑ 5 HAZARDOUS ❑ P1 PRODUCT 04 GASAHOL E; 3 MESEL BC EMPTY ❑ 95 UNKNOWN ❑5 JET FUEL. ❑6 AVIATION GAS D, IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF ❑2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) HAZARDOUS SUEISTANCE STORED$C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY M BOX A,B,C,a D C.A.S. 64 A. TYPE OF ❑ t DOUBLE WALLED SYSTEM1:13 SINGLE WALLED WITH EXTERIOR LINER �7 2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT LJ 95 UNKNOWN I STEEL/IRON ❑2 STAINLESS STEEL E] ❑99 OTHER B. TANK i 3 FIBERGLASS ❑4 STEEL CLAD W/FiBERGLASS REINFORCED PLASTIC MATERIAL ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑9 BRONZE ❑8 100%METHANOL COMPATIBLE FRP #tl GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTryER 5 GLASS LINING C. INTERIOR ❑ i RUBBEiUNED 11 ❑2 ALKYD LINING r� 3 EPDXYLINING ❑4 PHENOLIC LINING LINING ❑ �UNLINED ❑ ISLININGMATERIAL COVPATIBLEW"IX%METHANOL? ❑95 UNKNOWN_ ❑YES E]NO �OTHER �'�+✓1� D. CORROSION ❑t POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP PROTECTION ❑5 CATHODIC PROTECTION [:]91 NONE ❑4 FIBERGLASS REINFORCED PLASTIC ET95 UNKNOWN ❑99 OTHER IV. PIPING INFORMAT N CIRCLE A IF ABOVE GROUND U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE B. CONsrALCTJOM -INGL€WALLE[1 A U 2 DOUBLE WALLED A A U 95 UNKNOWN A U 99 OTHER U 3 LINED TRENCH A U 97 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 C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE (PVC) A U 4 FIBERGLASS PIPE A A U 9 GALVANIZED STEEL A A U 7 STEEL CLAP W/FRO U 91 NONE 95 UNKNOWN A U B 100%METHANOL COMPATIBLE FRP A U 99 OTHER V. LEAK DETECTION SYSTEMA CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM M P 5 1 VISUAL CHECK P 5 2 INVENTORY AECONCILIATIDN UST BE CIRCLED. P S 6 PRECISION TESTING P S 7 PRESSURE TESTING 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS P 91 NONE P S 95 UNKNOWN VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE P S 99 OTHER 1. ESTIMATED DATE LAST USED(MO/YR) 2 ESTIMATED OUANTI OF SUBSTANCE G IN3 WAST K FILLED WITH THIS FORM HA BEEN COMPL NS LETED UNDER PENALTY OF PERJURY3 AN TO Ti fF BES7LOF MY KN TERIAL? ❑YES []NO APPLICANT'S NAME{PAINTEQ&SIGNATURE} GE,IS TRUE AND CORRECT. DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION AGENCY# FACILITY I # ffE 0 TANK ID# CURRE LOCAL AGENCY FACILITY ID# D [� J APPROVED BY NAME I PERMIT HUMBER I�/A tt PHONE#WITH AREA CODE ��✓ PERMIT APPROVAL DATE PER IT XPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(a-29-Ba) THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A ENT FORMA" HASBEEN FILED DATA PROCESSING COPY