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'I^ -L trl! RES:IUP.CE DEFT TO <br /> G P.fid .0' <br /> STATE OF CALj;GRMASTATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEAL `'I•• .-' ' <br /> MARK ONLY I NEW PERMIT RFHEvIaI IYAMR �- <br /> CNE REN 2 INTERIM PERMIT O 9 CHANGE OE WFORr.IATON O T PERNANEnTIT CLOSED ON$IIT <br /> . AMENDED PERMIT CLOSURE a B TEMPORARY TANK E Q P TANK AEMOYEO <br /> DBA OR FACILITY NaAq riNERE TANK IS IN9'TALL£D: y�,� -;�,q,. 4— <br /> LTANK DESCRIPTION COMPLETE ALLITEMF- SPECICYIFUNKNOWN <br /> A. OwNER'$ TANK L 0.P <br /> B. MANUPACTURED EY, O C. DO u.bL,: CLL <br /> G DATE WSTALLED(MO'DATMEAR) G _� _ 93 <br /> 0. TAW O0ACi TY W QAlLON9; <br /> ILTANKCONTENTS <br /> IC&,I IS MARKED.COMPLETE ITEM C. J <br /> A, ® 1 MOTOR vemcLe FUEL A CIL 9. O 1A REGULAR '— <br /> ❑ E PETROLEUM p EMPTY C. UNLIIAOEJ � ° DIESEL ;� P AVIAT)ONGAS <br /> I❑� [o t PRODUCT bPREMIUM I_I A OASA40L U T MEI4AMOl <br /> Q S CHEMICAL PROONCT LJ PS UNKNOWN 2 WASTE UmEA0E0 5 JET FUEL <br /> O 2 LEADED W OTHER IDESCalli IN ITEM 0, SELOA, <br /> D. IF(A.1)If NOT MARKEO. ENTER NAME Of SUEFTA%II STORED <br /> -- _ C A s..' <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN 80XESA P,ANOC.ANO�pL TWAT APPLIES IN ROXO ANC <br /> A. TTPE OF ® ' DOUBLE wAll C 2 SNIOIE WALL WITH IXT(AIOR LwfR <br /> STSTEN PS UNKNOWN <br /> ❑ 2 SwOLE WALL A SECONDARY CONTAINMENT NAULTEOTANKI O 9P OITirm <br /> B. TANK ❑ 1 MRI STEEL D 2 STAINLESS STEEL ® 7 91 !RCLASS e STEEL CUD Vn FaEACLASS AEI-[ A <br /> O CED PLASTS <br /> MATERIAL B OONCRETE C i POLWmYI CHLOAIOE Q ) ALUMINUM ® B NWA METHANOL COMPAT� <br /> (PKKIary TANTO P NLl WIcgP <br /> BRONZE [� Io DALVANIUD STEEL ❑ 96 LANKnOwn 1M OTTER._ <br /> C.RRERIOR O I RVISER LIMED Q 2 ALXYO LNPp ❑ S EPDXY LINING D A PHENOLIC LwWG �r <br /> UNWG Q 5 GLASS LNINO D B UNLINED D 95 UNKNOWN Orwin Fi6p2 (y vay> <br /> IS LWINO MATERIAL COMPATIBLE WITH )CM METHANOLT YES_ NO— - <br /> D.CORROSION ❑ I POLYETHYLENE WRAP Q 2 CIOATINO S VINYL WRAP ® A c1i6AOLASS REIMFORCFD PLASTIC <br /> PROTECTLON 5 CATHOOIC PROTECTION n SI NONE n95 UNKNOWN <br /> ["'� w oTMEq_ <br /> E.SPILL AND OVERFILL SPILLLQNLWM6NTINSTALL40MAR) 6-/'9 i OVERFILL POEVENt10NFOl11PM <br /> EQUIPMENT INSTALLED NEAR) <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U /UNGERGROUNO.BOTMIFAPPLICABLE <br /> A. SYSTEM TYPE A u 1 SUCTION A( 2 PRESSURE A V 5 GRAVITY A U PP OTNFR <br /> B. CONSTRUCTION a U I slnpLE w•ll a�2 OOUILE WALL A U ] lWE9 TRENCH A U % UNKNOWN A U w O1HEA <br /> C. MATERIAL AND A V t RARE STIEL A U 2 STA"LESS STEEL A V S Po;IVVwYL CHLOgOE[PM=)a A nSEROLASS PIPE <br /> CORROSION A u B ALUMINUM A U t CONCRETE A u T STEEL w/couWG <br /> PROTECTION a v 9 GawAN1ze STEN • u ,o CATMOUIOPPOTECTIdT • u R 1QL7. METHANOL COYPATIIIE W/FAP <br /> A U PS UNKNOWN A U M OTHER <br /> D. LEAK DETECTION Q t AUTOMATICLog LEAK OETFOTOA Q E LWE TOMTNE95 T65 TWO ' <br /> IJNRORmC Q W DTHER_ <br /> V.TANK LEAK DETECTION <br /> O 1 VISUAL CMBCK Q 2 INVENTORY RECONCILIATION L J 2 YAOOTE MCNITOAW I64A AU'QMATIC TANK GAUGIN <br /> 06 NK TIST1N <br /> G M- S GROUND WATER MONITORING <br /> T Xi ® T INTEASTTULMOnITORNG <br /> ❑ PI MOVE D 95 UNKNOWN ❑ 9P OTHER <br /> VI.TANK CLOSURE INFORMATION - - <br /> I ESTWATEO DATE LAST USED AT/YR) 2.ESTIMA11 TE11 D 11 OUA11 11 WTI"OF <br /> T'l q SUBSTANCE REMAWWO I S.WAS TANKFILLEO WITH YES Q NpQ <br /> GALLONS INERT MATERIAL,T <br /> THIS FORM HAS BEENCOMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, yS TA <br /> APPLIOANTs NAME ------- UE AND CORREcT <br /> ,AArTAPA PKwTUAO OATS <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF TME POUR NUMBERS BELOW <br /> COUNTY# UURISDICTKNxf _FACllfhs - <br /> STATE I.D.b %• -- <br /> PE I NUM PEAMIT APPROVED BY/WTE -'-__-- I✓ 1 /•C ,� - <br /> - Md ExM4TION OATS <br /> FOAM B R•Pu THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION.FORM A,UNLESS A CURRENT FORM A HAS BEEN FILEO. <br /> 30 39Vd 'OCl�ty B h�NG'W h2iyW 5047-916 Eb:LO 666661 <br /> V/GZ/40 <br />