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STATE OF CALIFORNIA - <br /> �-- STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> MARK ONLY t NEW PERMIT G 3 RENEWAL PERMIT5 CHANGE OF INFORMATION J 7 PERMANENTLY Cl0 $ITE <br /> ONE REM 2 INTERIM PERMIT A (MENDED PERMIT � a TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: a eJ ti c n :I, R c'5 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.0.8 X -5 <br /> � S. MANUFACTURED BY: �000`r <br /> C. DATE INSTALLED(MGIDAY[YEAR) ,5 5 Li 0. TANK CAPACITY IN GALLONS: 10 G <br /> oo <br /> ILTANKCONTENTS IFA-11S MARKED.COMPLETE ITEM C. 1� <br /> A © t MOTOR VEHICLE FUEL a OIL 8. ,< Ula NLEADED 4 GGASAHOL IESEL IJ a AVIATION GAS <br /> 2 PETROLEUM 80 EMPTY 1 PROOUCT Ib PREMIIUMUNLEADED 5 :ET FUEL 7 METHANOL <br /> 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE Q 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW( <br /> 0. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.m: <br /> III. TANK CONSTRUCTION MARK ONE ITEMONLY IN BOXES A.B.ANOC.AND ALL THATAPPLIES IN BOX D AND <br /> A. TYPE OF LYJ t DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> B. TANK i BARE STEEL LI 2 STAINLESS STEEL ;� 3 FIBERGLASS A STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 5 CONCRETE 8 POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIBLE W/FRP <br /> (PdmoyTank) 9 BRONZE C 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING A PHENOLIC LINING <br /> C.INTERIOR 5 GLASS LINING B UNLINED 95 UNKNOWN 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO_ <br /> D.CORROSION I� I POLYETHYLENE WRAP 1—' 2 COATING _I 3 VINYL WRAP a FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION n 91 NONE � 95 UNKNOWN 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR)_ 1110� OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAM ICI J <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U I SINGLE WALL A 0 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U 1 SAFE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U a CONCRETE Ao 7 STEELWICOATING A U B 100% METHANOL COMPATIBLEWIFRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION <br /> A U 95 UNIG90WN A U 99 OTHER <br /> D. LEAK DETECTION C:j 1 AUTOMATIC LINE LEAKOETECTOR ❑ 2 UNETICHTNESSTESTING NOKRORMG '� 99 OTHER <br /> V.TANK LEAK DETECTION <br /> I VISUAL CHECK 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING �^ 4 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING <br /> 8 TANK TESTING 7 INTERSTMALMONITORING 91 NONE IJ 95 UNKNOWN - 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MOOAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES a NO <br /> SUBSTANCE REMAINING INERT MATERIAL? <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF JURY, CI T� TH ES OF MY KNOWLEDGE IS TRUE AND CORRECT <br /> APPLICANTS NAME OATS <br /> IPMWEDAS AWW 410 Cz- :Yo({AISPea �-/(D _ f <br /> LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OF THE URNUMBERS BELOW <br /> COUNTY# JURISDICTION# CIL TANK# t4r -1 <br /> STATE I.D.# c I C7 , k-tti'1 <br /> PERMIT NUMBER I PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. <br /> FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMS (12-91) ^ �� FDWmA9Aa <br />