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STATEOFCAUFOIUTA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ED7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT F74 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNERS TANK I.D.# S. MANUFACTURED BY: C. DATE INSTALLED(MOIDAY/YEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-11SMARKED.COMPLETE REM C. A. 1 MOTOR VEHICLE FUEL ❑ 6 OIL B. 0- aUNLFAL DED 3 DIESEL ❑ 8 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY PRODUCT ❑ 1D PREMIUM 4 GASAHOL ❑ 7 METHANOL ❑ ❑ ❑ ❑ 2 LEADED O 99 JOTHERL(DESCRIBE IN ITEM O.BELOW) 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTR TION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALLTHAT APPLIES IN BOX D AND A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER S. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYO LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINUi% C.INTERIOR ❑ 5 GLASS LINING ❑ 8 UNLINED ❑ 95 UNKNOWN ❑ w OTHER IA`I'i LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO_ D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EOUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A DOUBLE WALL A U 3 LVED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A(95 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 0. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ O MONERSTIT IAL ITORING ❑ 99 OTHER V.TANK LEAK DETECTION 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING F-15 GROUND WATER MONITORING e TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.E ESTIMATED DATE LAST USED(MO/OAY/VR) 2.ESTIMATEDOUANTITYOF 3.WAS TANK FILLED WITH YES ❑ �❑ SUS STANCEREMAINING GALLONS WERTMATERIAL7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE IRRWN DA 3WNANREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# �FACILITY � TANK# STATE I.DA m L_Ll�ll PERMIT NUMBER PERMIT APPROVED BV/DATE PERMIT EXPIRATION DATE FORM a (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. v / FOROO1tORS