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4` STATE OFCALIPoRNA .� ...••�es STATE WATER RESOURCES CONTROL BOARD _ UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B a; � • o COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED O/ DBA OR FACILITY NAME WHERE TANK IS INSTALLED: / C 310 _ I. TANK DESCRIPTION aompLpE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK 1.0.8 B. MANUFACTURED BV: C/ C. DATE INSTALLED(MOIDAY/YEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-I IS MARKED,COMPLETE ITEM C. A. i t MOTOR VEHICLE FUEL 4 OIL B. / C ❑ UNLEA E� ] DIESEL Q 8 AVIATION GAS 2 PETROLEUM W EMPTY `L�JI 1 PRODUCT Ll!1 Ib PREMIUM 4 GASAHOL 7 METHANOL UNLEADED 5 JETFUEL '❑ 7 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE C:] 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOVR O IF(A,I)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.8: III. TANK CONSITTRRUCTION MARK ONE ITEM ONLY IN BOXES AB.AMC)C,AND ALL THAT APPLIES IN 80X0 A. TYPE OF ❑,—,/1�BLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM Ljd' 2,,SINGUE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ N OTHER B. TANK 9� I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 P18ERGLASS ❑ 4 STEEL CLAO W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE '❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPAT18LE WIFRP (PnmaryTank( ❑ 9 BRONZE ❑ III GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ] XV LINING ❑ 4 PHENOLIC LINING / C.INTERIOR ❑ 5 GLASS LINING F76 UNLINED 95 UNKNOWN ❑ 9D OTHER [/ LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— D.CORROSION ❑ I POLYETHYLENE WRAP ATING ❑ ] VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION AR 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U S ALUMINUM A U .8 CONCRETE A U 7 STEEL:COATING A U 8 100% METHANOL COMPATTBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHOOICPROTECTION U UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ T WEASTITtALMONITOMHO 99 OTHER V.TANK LEAK DETECTION �I ❑ I VISUAL CHECK ® 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION I.ESTIMATED DATE LAST USED(MOIOAYP/R) 2.ESTIMATED OUANTTV OF 3.WAS TANK FILLED WITH YES E::] NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE 1 WtlNTEO a 9GNATUH1a1 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY x JURISDICTION x FACILITY x TANK x STAT I.D. ESE] ET-1-1 D U PERMIT NUMBER PERMIT APPRO SD BVEVIDATE I PERMIT EXPIRATION DATE FORM B (mm THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. PoIp0H88a