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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> f:l <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT = 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT E-1 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 7I MCo TA-L)c_ie— P�s�2� <br /> I. TANK. DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A OWNER'S TANK I.D.,v .117- 1 8. MANUFACTURED BY: /vi 0 <br /> C. DATE fNSTALLED(MO/DAYIYEAR) App-, -78 D. TANK CAPACITY IN GALLONS: <br /> IL TANK CONTENTS IF A-1 IS MARKED.COMPLETE I7EM C. <br /> A- 5�11 MOTOR VEHICLE FUEL 4 OIL B. C. to REGULAR UNLEADED L 3 DIESEL E] 6 AVIATSCN GAS <br /> 1b PREMIUM UNLEADED E::] 4 GASAHOL F 7 METHANOL <br /> 2 PETROLEUM ❑ BO EMPTY 1 1 PRODUCT II tc MIDGRADE UNLEADED 5 JET FUEL E 8 M85 <br /> 3 CHEMICAL PRODUCT El 95 UNKNOWN 2 WASTE 4 (� 2 LEADED a 99 C71-fEr3(DESCRIBE IN TTEM 0.BELOW} <br /> 0, IF(A.1(IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.N: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D AND E <br /> A TYPE OF !� 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LNER u 5 INTERNAL BLADDER SYSTEMA C] 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL O 4 SINGLE WALL IN A VAULT a 99 OTHER <br /> B. TANK 1 BARE STEEL 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 5 CONCRETE 6 POLYVINYL CHLCRIDE 7 ALUMINUM 8 100k METHANOL COMP.ATIBLEW/FRP <br /> (Primary Tank) 9 BRONZE tC GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> C.INTERIOR I RUBBER LINED 2 ALKYD LINING 3 EPDXY UNING 4 PHENOLIC LIMNG <br /> LINING OR Q 5 GLASS LINING ` B UNLINED 95 UNKNOWN 99 OTHER <br /> COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES—✓/NO_ <br /> D-EXTERIOR 1 POLYETHYLENE WRAP 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> CORROSION <br /> PROTECTION 5 CATHODIC PROTECTION I_; 91 NONE 95 UNKNOWN 99 OTHER <br /> E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT 1 TALLED(YEAR) OVEHFILL aPREVENTiON EQUIPMENT INSTALLED(YEARI <br /> DROP TUBE YES NO STRIKER PLATE YES ✓ NO DISPENSER CONTAINMENT YES NO <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION Ao 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A& 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATPBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> 1 UE00MTiSL IFIE LEAN 2 UNE i1GHINESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC UNE 5 A.UTCIA4TIC PUMP ��T <br /> D. LEAK DETECTION 13ETECTOR TEST NG MOM on <br /> G �—•' LEAK DETECTOR SMTCCWN E 99 OTHER <br /> V.TANK LEAK DETECTION <br /> t VISUAL CHECK 2 RECONCILIATION <br /> 3 VADOZE MONITORING 4 AUTOMATGAUGING MONITORING <br /> TANK 5 GROUND WATER <br /> 6 �SNTINGTANIK <br /> 7 <br /> MONITORCONTINUOUS B SIR 0 9 WEEK GA MANUAL 10 TEST <br /> MON,HLY TANK 95 UNKNOWN 99 OTHER <br /> NG <br /> VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) <br /> 1.ESTIMATED DATE LAST USED(MOICDAY/YR) f�AD 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> A J <br /> , SUBST �ANCE REMAINING GALLONS INERT MATERIAL? <br /> THIS FORM HAS BEEN COMPLETED UNDER ENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, 1S TRUE AND CORRECT <br /> TANK OWNER'S NAME DATE <br /> (PRINTED A SIGNATURE) Y1 A+KJ. u-- ( I <br /> LOCAL AGENCY USE ONLY THE ST .NUMBER I OMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION N FACILITY R TANK d OCZ <br /> STATE 04 0 LLS c_ 7J g 7 <br /> PERMIT NUMBER I PERMIT APPROVED BY/DATE 1 PERMIT EXPIRATION DATE Lt <br /> =y <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETEO FOR INSTALLATIONS. THIS FORM <br /> SHOULD BE ACCOMPANIED BY A PLOT PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM B (6-95I <br />