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0 19 <br />STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br />c " <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br />MARK ONLY ® I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSET � E <br />ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ - ,• <br />8 TANK REMOVED '�R�1 <br />DBAOR FACILITY NAME WHERE TANK IS INSTALLED: Sap61CC1TE0.10ER tloq 192 talAo-W pot Lafhpop C0. <br />I TANK nFSCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br />A OWNER'S TANK I.D.# /O L1_ U <br />B.G. <br />❑%� 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS <br />1D PREMIUM UNLEADED ❑ 4 GASAHOL ❑ <br />❑ 7 METHANOL <br />B. MANUFACTURED BY: / l <br />Ee <br />/N <br />C DATE INSTALLED (MCIDAWYEAR) 06- /Y-7 <br />g' <br />❑ 2 LEADED ❑ 99 OTHER IDESCRIBE IN ITEM O. BELOWI <br />D. TANK CAPACITY IN GALLONS: <br />/ 000 <br />U <br />u TA U V MnAITCAITC o� c.[ rtcu n <br />A ® 1 MOTOR VEHICLE FUEL ❑ 4 OIL <br />B.G. <br />❑%� 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS <br />1D PREMIUM UNLEADED ❑ 4 GASAHOL ❑ <br />❑ 7 METHANOL <br />❑ 2 PETROLEUM ❑ 80 EMPTY <br />LN 1 PRODUCT <br />❑ Ic MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 <br />❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN <br />❑ 2 WASTE <br />❑ 2 LEADED ❑ 99 OTHER IDESCRIBE IN ITEM O. BELOWI <br />D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. # <br />III TANK f -r) ICTRIN:TI('1N u"RKnN[ ITEM nNI Y IN BOXES A B AND C. AND ALL THAT APPLIES IN BOX D AND <br />nlmun u1Cnt1al ATIAKI cenuun ne 11 ¢u1Jn[P!_Pnl Mn RIYTH IF APPLICABLE <br />A. <br />® 1 DOUBLE WALL <br />❑ 3 SINGLE WALL WITH EXTERIOR LINER <br />❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN <br />A. TYPE OF <br />SYSTEM <br />❑ 2 SINGLE WALL <br />❑ 4 SINGLE WALL IN A VAULT <br />❑ 99 OTHER <br />CONSTRUCTION <br />❑ I BARE STEEL <br />❑ 2 STAINLESS STEEL <br />❑ 3 FIBERGLASS <br />❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC <br />B. TANK <br />MATERIAL <br />❑ 5 CONCRETE <br />❑ S POLYVINYL CHLORIDE <br />❑ 7 ALUMINUM <br />© 8 100% METHANOL COMPATIBLE W/FRP <br />(Primary Tank) <br />❑ 9 BRONZE <br />❑ 10 GALVANIZED STEEL <br />❑ 95 UNKNOWN <br />❑ 99 OTHER <br />M:CXAl11CAl ONE IFAIt ❑ <br />OEIECT011 <br />❑ I RUBBER LINED <br />❑ 2 ALKYD LINING <br />❑ 3 EPDXY LINING <br />❑ 4 PHENOLIC LINING <br />C. INTERIOR <br />LINING OR <br />❑ 5 GLASS LINING <br />❑X 6 UNLINED <br />❑ 95 UNKNOWN <br />❑ 99 OTHER <br />COATING <br />IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? <br />YESZ NO— <br />D. EXTERIOR <br />❑ 1 POLYETHYLENE WRAP ❑ 2 COATING <br />❑ 3 VINYL WRAP <br />® 4 FIBERGLASS REINFORCED PLASTIC <br />CORROSION <br />❑ PROTECTION ❑ 91 NONE <br />❑ 95 UNKNOWN <br />❑ 99 OTHER <br />PROTECTION <br />5 CATHODIC <br />SFEZC FTAINMENTIySTALLED(YEAR) <br />OVERFILL REVENDON EQUIPMENT INSTALLED(YEAR) <br />� DISPENSER CONTAINMENT YES V NO <br />E. SPILL AND OVERFILL, <br />BIC. DROP TUBE YES <br />✓ NO _ STRIKER PLATE <br />YES NO <br />nlmun u1Cnt1al ATIAKI cenuun ne 11 ¢u1Jn[P!_Pnl Mn RIYTH IF APPLICABLE <br />A. <br />SYSTEM TYPE <br />A U <br />1 SUCTION <br />A U 2 PRESSURE A U <br />3 GRAVITY A U <br />4 FLEXIBLE PIPING A U 99 OTHER <br />B. <br />CONSTRUCTION <br />A U <br />1 SINGLE WALL <br />A(D 2 DOUBLE WALL A U <br />3 LINED TRENCH A U <br />95 UNKNOWN A U 99 OTHER <br />C. <br />MATERIAL AND <br />CORROSION <br />PROTECTION <br />A U <br />A U <br />A U <br />1 BARE STEEL <br />5 ALUMINUM <br />9 GALVANIZED STEEL <br />A U 2 STAINLESS STEEL A U <br />A U 6 CONCRETE A U <br />A U 10 CATHODIC PROTECTION <br />3 POLYVINYL CHLORIDE (PVC)A U 4 FIBERGLASS PIPE <br />7 STEEL W/COATING AOB 100% METHANOL COMPATIBLE WIFRP <br />A U 95 UNKNOWN A U 99 OTHER <br />D. <br />LEAK DETECTION <br />®1 <br />M:CXAl11CAl ONE IFAIt ❑ <br />OEIECT011 <br />2 UNE TBHRff9a ®3 LWmN0116 W1EI6fmAL ❑ d EIECIROVk TINE ® <br />'ME 7G MGMtplaro IFAK OE1ECroR <br />5 AUr C PUW ❑ 99 OTHER <br />sM19Gvm <br />V TANK I FAIL ITFTFCTION <br />❑ 1 VISUAL CHECK ❑ 2 RECO CILIATIONORY ❑ 3 MONITORING ®4 AUTOMXTIGAUGING C TANK ❑ 5 MONITORINGGROUND ❑ 8 ANNUALTESTING <br />7 MON NUOU INTERSTITIAL ❑ a SIR ❑ 9 TANK GAUGINGAL ❑ 10 TCSNTHCY TANK ❑ 95 UNKNOWN ❑ 99 OTHER <br />VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) <br />1. ESTIMATED DATE LAST USED(MO/DAYNR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES❑ NO❑ <br />SUBSTANCE REMAINING GALLONS INERTMATERIAL7 <br />THI" ^"" ""� Dora nna•cI cTcn I IAInFA? PFAIAI Tv of PERJURY. AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />TANK OWNER'S NAME <br />(PAINTE015 <br />A 51GN,i}IREj <br />•t�yrE crus Gil Ailyn� .1 <br />LOCAL AGENCY USE ONLY THE STATE 1.6. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br />COUNTY # JURISDICTION # FACILITY # 00%051% TANK If p0 <br />STATE I.D.# m 0 1 5FET(Hl o s g g <br />PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE <br />THIS FORM MUST BE HOULD BE PANIEDACCOMPANIED <br />HIEDY A BY IT A, <br />PWLE ORM THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THUNLESS A CURRENT FORM A HAS BL� "mu. IWRGROUND STORAGE TANK REGULATIONS y <br />SHOULD BE ACCOMPANIED BY A PLOT PW <br />LE <br />(6-95) y—/k %t? I#L5 th 5/raD/98' � d-"5 <br />