Laserfiche WebLink
... .• AC... _., I-HUF1 :TFdI CO EN! PESIOLIPCE DEFT TO a - <br /> NIII� <br /> ..i <br /> 0- <br /> STATE Or CALFORtA .•• <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B (Z <br /> sa :a <br /> �. .wl <br /> COMPLETE A SEPARATE FOAM FOR IEACN TANK SYSrm <br /> MARK ONLY r%;�, t NEW PERMIT O ] RENCral ASTT 9 CHANGE OF WFORM.7ON D 7 PERMANEN%Y CLOSED ON SLIT <br /> ONE REM o 2 INTERIM PERMIT . AVENCEO PERMIT <br /> ❑ t TEMPORARY TANK CLOSUPE t TANK REMOVED <br /> DBA OR FACILITY NAMEWNERETANK 13INSTALLEDi BeY4e7b Tq Tk LINE 16 4(, <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK L D.. 2. MANUPA4TURED BY E7 C <br /> Docc64 tL�L <br /> T I ..w LR nI 7 S D. TATA( CAPACITY W GALLONS IS 0OC—) <br /> II.TANK CONTENTS IFA-I 19MARKEO.COMPLETE ITCMC. <br /> A. ® 1 MOTOR VEHICLE FUEL A OIL9 . t. A <br /> C2 04311 <br /> — <br /> ❑ WAFGVVLEAOEC ❑ i AVIATIONG,5 <br /> O t PETROLEUM a 90 EMPTY ® 1 PRODUCT1D PRE MIUM U A CASAHOL U I METHANOL <br /> ❑ 2 CHEMICAL►WDNCT L7 OS UNKNOWN CD2 WASTE [71 2 IFLEA060 5 AETrUEL <br /> W OTHER (Di SCR:BE IN ITEM O. BELOW <br /> DED <br /> D. Ic(A,g4MOT M♦RKEO. ENTBp NAME OFSUOSTANCE STORED _ <br /> III. TANK CONSTRUCTION MAAXOhfITEMONLYINBOXESAS.ANOC.ANOALLTWAT APPLIES INBOXOANOE <br /> A. TYPE OF ® 100w a WALL S SINGLE WALL WITH EXTERIOR LWEA ❑ 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL A SECONDARY❑ CONTAINMENT NAUlTEO?ANA O 90 OT.ER <br /> B. TANK ❑ 11AA9 STEEL D 2 STAINLE95 STEEL ® 1 F19tACLASS A STEELCLAO vn c19ERQAiS REINCORGEO PLA.TC <br /> MATERIAL ❑ i CONCRETE ❑ i POLYVINYL CHLORIDE ❑ 7 ALUMINUM ® B IDDM METHANOL COMPAT�ALE WIFRP <br /> (DKKMIY7r1Y1 D 9 BRONZE n 19 GALVANIZED 9111L D 95 LAVKNOWN [7 99 OTHER <br /> UM <br /> ED D 2 ALAYp lwrO Q S EPDXY LINING D a DMENOLc LINING <br /> C.RLINMINp UNeo / <br /> LINING <br /> 1 RUBBER S GLASS L9O a CD9 UND 9S UNKNOWN D W On.ER �/per 674q--�n, <br /> IS LWINO MATERIAL COMPAOBLE WITH toy. METHANOL? YES— NO- <br /> ---------------- <br /> D, <br /> O_,D.CORROSION ❑ ' POLYEAIYLEW WRAP ❑ 2 OOAT04 D ] VINYL WARP . F19ERCLASS Ai NPORCED PLASTIC <br /> PROTECTION D S CATMOOK;PAOTECTK]N n 91 NONE n 95 UNKNOWN n W OTHER <br /> E.SPILL AND OVERFILL VOILLCONTAINMENT INSTALLED(YEAIu--(2-1OVERFILL PREVENTIGNEWIPNENTINSTALLEOnARI <br /> IV.PIPING INFORMATION CIRCLE A 1F ABOVE OROUND OR U /UNDEAGROUNO.9ONIP♦PPLICA9LE <br /> A. SYSTEM TYPE- A v I SuCTON A(D 2 PRESSURE A V S GRAVITY A U 99 ONFA <br /> B. CONSTRUCTION A U T SINGLE WALL A©2 OOVOLE WALL A U 2 LINED TRENCH A U 9S UNKNOWN A V 99 OTHER <br /> C. MATERIAL AND A U t BARE STEEL A U 2 STA"LES9 STEEL A U 7 POLYVINYL CHLO1IOE(1Vg1 a npEROLASS PIPE <br /> CORROSION A U 9 ALUMINUM A U 6 COMCRETE A U 7 STEELWi COATING ♦ Y A +DLT. METHANOL COMPATIftE mePP <br /> PROTECTION a v 9 G♦l V♦N12E0 STEEL A U +D CATHODICPAOTECTbI <br /> A U 95 UNKNOWN A U W OTHER <br /> 0. LEAK OETECDON ❑ t AUTOMATIC UNE LEAK DETECTOR O 2 UNE T4Naoal <br /> NTHESSTESTPK) I 99 OTHER- <br /> V. <br /> r OTHER <br /> V.TANK LEAK DETECTION <br /> ❑ I VISUAL CMECK ❑ 2 94VENTORY RECONCILIATION D S VAOOZE MON17CAING A AUTOMATIC TANK GAUGING L J 5 GROUND WATER MONITORING <br /> ❑ A TANK TESTNO ® 7 INTERSTITIAL MONITORING C—j 9t NONE J 95 UNKNOWN _ ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION - <br /> t.EST9AATEDQITEUSTU9E0f AAT/Yw 2.E6TIMATEo OUTH ANnTYOF S.WAS TANKFILLEO WI <br /> N( W96TAHOE REMAINING GALLONSI INERT MATLAIALf YES D NOD <br /> rH/S FORM HAS BEER IOMPLE7ED UNDER PENALTY OF PERUURY.,ANO TO NNE®EST OF A1Y KNOWLEDGE. /S TRUE AND CORREC r <br /> APPLICAHT9 NAME "'- <br /> PA•T9P•.nKAIVAO DATE <br /> MA,eolAI E 6rX61,c <br /> LOCAL AGENCY USE ONLY TME STATE 1.0.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY JURISDICTION III P <br /> STATE 1.0.E <br /> ►E I NUMBQ� o TV <br /> I PERMIT APPROVED EY/WTE Md EXPIRATION CATS <br /> FOAM 9 p•ru THIS FORM MUST BE ACCOMPANIED BY A PERMR APPLICATION•FORM A,UNLESS A CURRENT FORMA MAS BEEN FILEO. <br /> Be 391jd 'OLIo3C IS A-�NUW haCW 4-ssy-Bvv-916 C7 :L0 E66T/6Z/V0 <br />