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"' Imo' :TFit1 CC Eflf, RESOURCE DEFT TO <br /> 3151 c,ti-7=6� F.fi3 'n <br /> STATE Ok'4UPOINA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> aa: :: <br /> C014PLETE A SEPARATE FORM FOR EACH TANK SYSTEAL <br /> MARK ONLY r%C;l T NEW PERMIT7 RENEWAL FIRMR __ ' `"•• •• <br /> ONE ITEM 2 INTERIM PERMIT O AMENCEO PERMIT D CHANOF OF WFORUATION O r DEAN ANENTLT CLO$ D <br /> c <br /> ❑ ♦ TEMPORARY TANK CLOSVAE � P TANX PFMOvFO <br /> DBA OR fACILRY NAIL WHERE TANK 13 INSTALLED! Be,./CTo TaNk LY.�E —'� <br /> -. 18 QL , <br /> I. TANK DESCRIPTION COMPLETEALLITFM9_ aPECIPYIEUNKNrnVN � <br /> A.pWNERs TANK 10 P <br /> B. wNulAL1URE08Tp C DO CI.b� qLL <br /> G DATE NSTALLED(MODAYMEAR) G _� _ C� <br /> 3 0. TAW( C.VACITr W GALLONS. <br /> II,TANK CONTENTS IFA-1 ISMSRK£D.COMPIETEITCMC. <br /> A, ® 1 MOTOA VEHICLE FUEL I OIL I 9. O to 0.EGVUR '—' J <br /> ❑ I PETROLEUM AO EMPTY ® C. UNLEAOEJ ""� A 04391. I ❑ E AVIATION GAS <br /> 1 PRODUCT TDPR'e MIUM I I <br /> Q S CHEMICAL FRK70UCT ❑ DS VNKNOWN CD2 WASTE D 2 IEtEAOHCO 5 SFT FUEL _j 7 METHANOL <br /> . 99 OTTER OD'CA BE IN ITEM D, SELOw, <br /> 0. 6(A,gq MOT MARKED. ENTER NAME OF SUBSTANCE STOAEO <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN SOXESA_A.AND C.AND ALL THAT APPLIES IN SOXD AIDE <br /> A TYPE OF ® 1 DOUBLE WALL C, 2 SINGLE WALL WITH FIIEROR LINEA Q Ds UNKNOWN <br /> SYSTEM D I SINGLE WALL ❑ A SECONDARY CONTAINMENT (VAULTEOTAN,O ✓� w OTHER <br /> 8. TANK ❑ I V'ta STEEL Q I STALNLISS STEEL ® 2 FIEIRCLASS a STEEL CIAO vu E:BERGIASS REINc P <br /> O CED DIA$!{ <br /> MATERIAL ❑ E OONCAETE ❑ E POLYvINn CHLORK7F ❑ 7 ALUMINUM ® B 1W,. METWANOI COWPAT'iL1 WIPRF <br /> (DAIRAry Trlq ❑ D BRONZE L J TO GALVANIZED STEEL ❑ 97 UNKNOWN <br /> L, PD Dn�£R <br /> C.INTERIOR 1 MUSSER LINED ❑ 2 AL%YO LINING ❑ S EPDXY LINING ❑ a PNENOLC LINIhG <br /> UND4 Q S GLASS LINING ❑ A UNLINED " UNKNOWNP' I' ye 0!uF2 <br /> O LWwO MATERIAL ODMPATSLE Term +OPT. MCrH,MC%? YES— NO— J <br /> D.CORROSCN O 1 POLYETHTtf NE WRAP n 2 OOATNIO a S VINYL W0.K • cIi ERGLASS AEiNf ORCED PLASTK: <br /> PROTlCTIOEI C-7s CATTg70K;PROTECTION n Bl none NIB UNKNOWN n 9q OT.EA <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(TEAA7 OVERFILLPREVENTIph FOUIPMCNT INSTALLED,h EAR) <br /> IV,PIPING INFORMATION CIRCLE A If ASOVF OROUNO OR U M LINDE ROROUNO.SOT.If APFLIDs AIf <br /> A SYSTEM TYPE A u + SUCTION A(D2 PRESSURE A V S GRAVITY A U ED OTHER <br /> B. CONSTRUCTION A U T MINGLE WAIL A D2 DOUBLE WALL A U 2 LINED TRENCH A U % UNKNOWN A V qq OT.EA <br /> C. MATERIAL AND A U 1 SAAE ITIEL A U 2 37AMLESS STEEL A V S POLwwrL CMLOaOE(PVC)A A cIBEROLIRS PmE <br /> CORROSION A U 9 ALUMINUM ♦ y { CONCRETE A U 7 STEEL W/COATING A U / Ipp, uE THAAOL OOMIATIBaE WdPp <br /> PAOTECTIOH A U 9 OALVANL2F0 STEEL A U ID CATMODIOPROTECTION <br /> A V 95 UNKNOWN A U W OTHER <br /> O. LEAK DETECTION Q 1 AUTOMATIC LINE LIAK OETECTOA 0I UNE TOMTNESS Y&$TwO ' r-I 'A <br /> .JNrtORINC ❑ OTMER <br /> v.TANK LEAK DETECTION <br /> ❑ 1 VISUAL CHECK Q 2 INVENTORY RECONCILIATION n S VADOZE MONITOAWO a AU'OMATIC TANX GAUGLIO <br /> LeypI n S GROUND WATER NONITORINO <br /> A TANK TESTING 7 GATE ABTITIIL MON-70Art+G G 91 rpME 95 UNKNOWN a 9R OTMEA <br /> VI.TANK CLOSURE INFORMATION -- <br /> 1.ESTwArEDOATELAST USEAYNR) 2 FSTIMATEOCUANTITTOP S.WAS TANKFALEO WIIM <br /> V " SUBSTANCE REMAINING OALLONSI INE AT MATE WALL YES ❑ NO� <br /> THIS FORM HAS BEEN tOMPLETED UNDER GEIVALTY OF PfR.JUAY,AND TO THE®ESTOP'tidy KNOWLEDGE, is TATUE AND CORRECT <br /> APPLICANTS NAHE ---"-' <br /> IW�TlDA PawArvAE1 / y ,(",/� DATE <br /> M4gobq E G r 66,Cc {/�nnQ r1.. - <br /> LOCAL AGENCY USE ONLY THE STATE'0-NUMBEA IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> STATE LD.# <br /> COUNTY JURISDICTIONS P <br /> ►£ I NUMB PFR MYAPPAOYFOAYDATE —9 , Cl MR EXNAATION OP7E vY <br /> I-PlEIR <br /> FOAM B (?-Fl) THIS FORM MUST BE ACCOMPANIED BY A PERMR APPLICATION•FORM A.UNLESS A CURRENT FORM A HAS BEEN FILED, <br /> 80 39G'd 'CCISSC B A-IN-vH A.IVH 4_e_sl-ovv-9T6 Et, :LO E661/6L/VO <br />