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• <br />0 <br />STATE OF CAUFORNIA <br />STATE WATER RESOURCES CONTROL BOARD m� ' <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B , <br />) <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br />MARK ONLY 1 NEW PERMIT Q 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED <br />ONE ITEM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED <br />DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 5( ER LuEe 4lof 17; (,ofAlrop Rd. L tArU (,a <br />I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br />A OWNER'S TANK 1. D. /OY- (! B. MANUFACNRED BV: MooeE �.Y 6,1FL Hq <br />C. DATE INSTALLED(MO/DAYNEAR) D69g D. TANK CAPACITY IN GALLONS: 29d000 li <br />11 TAAIII fenMTCMTC .e e . m ueev n rnuol FTF ITFM C <br />A ® 1 MOTOR VEHICLE FUEL ❑ 4 OIL <br />B. <br />C. ❑ le REGULAR UNLEADED ❑ 3 DIESEL Q 6 AVIATION GAS <br />® tb PREMIUM UNLEADED Q 6 GASAHOL ❑ 7 METHANOL <br />❑ 2 PETROLEUM Q 80 EMPTY <br />® 1 PRODUCT <br />Q Ic MIDGRADE UNLEADED Q 5 JET FUEL ❑ 8 M85 <br />Q 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN <br />Q 2 WASTE <br />Q 2 LEADED O 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br />D. IF (A7) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. #: <br />111 TAAIV rnMCT011CTInM .. eev nuclsu nulvlN RnYFRA R ANDC. ANDALLTHATAPPLIESINBOXDANDE <br />IIF DIDIMP_ IMC11DMATInM 11.1.. A .. RnVP PR lIND OR U IF UNDERGROUND. BOTH IF APPUCABLE <br />A. SYSTEM TYPE <br />L^J i DOUBLE WALL <br />Q 3 SINGLE WALL WITH EXTERIOR LINER <br />Q 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN <br />A. TYPE OF <br />SYSTEM <br />❑ 2 SINGLE WALL <br />❑ 4 SINGLE WALL IN A VAULT <br />Q 99 OTHER <br />A U <br />❑ I BARE STEEL <br />Q 2 STAINLESS STEEL <br />❑ 3 FIBERGLASS <br />❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC <br />B. TANK <br />MATERIAL <br />Q 5 CONCRETE <br />Q 6 POLYVINYL CHLORIDE <br />Q 7 ALUMINUM <br />® 8 100% METHANOL COMPATIBLE W/FRP <br />(Primary Tank) <br />❑ 9 BRONZE <br />Q 10 GALVANIZED STEEL <br />Q 95 UNKNOWN <br />Q 99 OTHER <br />2 ME INHRF55 3 =uWS IHIEF6TIML 1 BECmOtaC OMi <br />TEm9G ® MGNidVNG ❑ IEAK bDEGTGR <br />❑ 1 RUBBER UNED <br />Q 2 ALKYD LINING <br />Q 3 EPDXY LINING <br />Q 4 PHENOUC LINING <br />C. INTERIOR <br />LINING OR <br />Q 5 GLASS LINING <br />6 UNLINED <br />Q 95 UNKNOWN <br />❑ 99 OTHER <br />COATING <br />IS LINING MATERIAL COMPATIBLE <br />WITH 100% METHANOL? <br />YES --LINO— <br />D. EXTERIOR <br />❑ 1 POLYETHYLENE WRAP <br />Q 2 COATING <br />Q 3 VINYL WRAP <br />© 4 FIBERGLASS REINFORCED PLASTIC <br />CORROSION <br />❑ PROTECTION <br />71 91 NONE <br />❑ 95 UNKNOWN <br />❑ 99 OTHER <br />PROTECTION <br />5 CATHODIC <br />SPILL CONTAINMENT IN TALLED (NEAR)IY75 <br />OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) <br />NO <br />E. SPILL AND OVERFILL, BIC. DROPTUBE YES <br />NO STRIKER PLATE YES ✓ NO_ <br />DISPENSER CONTAINMENT YES <br />IIF DIDIMP_ IMC11DMATInM 11.1.. A .. RnVP PR lIND OR U IF UNDERGROUND. BOTH IF APPUCABLE <br />A. SYSTEM TYPE <br />A U <br />1 SUCTION <br />A 02 <br />PRESSURE A U <br />3 GRAVITY A U <br />4 FLEXIBLEPIPING A U 99 OTHER <br />B. CONSTRUCTION <br />A U <br />1 SINGLE WALL <br />A (9 <br />2 DOUBLE WALL A U <br />3 LINED TRENCH A U <br />95 UNKNOWN A U 99 OTHER <br />C. 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 <br />A U <br />A U <br />2 STAINLESS STEEL A U <br />6 CONCRETE A U <br />10 CATHODIC PROTECTION <br />3 POLYVINYL CHLORIDE (PVC)A U 4 FIBERGLASS PIPE <br />7 STEEL W/ COATING A UO B 100% METHANOL COMPATIBLE W/FRP <br />A U 95 UNKNOWN A U 99 OTHER <br />D. LEAK DETECTION <br />® <br />1 =c '=R' WE IFMA <br />oEIEGTGR ❑ <br />2 ME INHRF55 3 =uWS IHIEF6TIML 1 BECmOtaC OMi <br />TEm9G ® MGNidVNG ❑ IEAK bDEGTGR <br />5 A9IGLMTC WAP 99 OTHER <br />snnoovm ❑ <br />V. TANK LEAK DETECTION <br />I�Q 1 VISUAL CHECK ❑ 2 RECONCILIATION CILIATIONORY ❑ 3 VADOZEMONITORING 4 GAUGING AUTOMATIC TANK Q 5 GROUND MONITORING TER ❑ 6 TTEESTINGTANK <br />Yom-' 7 MONITORING INTERSTITIAL ❑ g SIR ❑ 9 WEEKLY <br />GAUGINGAL ❑ 10 E9TNG LY TANK Q g5 UNKNOWN Q 99 OTHER <br />VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) <br />I. ESTIMATED DATE LAST USED(MODAY/YR) 2. ESTIMATED QUANNTY OF 3. WAS TANK FILLED WITH YES E:]NO❑ <br />SUBSTANCE REMAINING GALLONS INERT MATERIAL? <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />TANK OWNER'S NAME DATE p LSI <br />IP OAMGNA E)SC/ )�J QS -I 41-n <br />LOCAL AGENCY USE ONLY THE STATE I.D. NqlMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br />COUNTY # JURISDICTION # FACILITY 007059 TANK # ODe3 <br />STATE I.D.# rn = 151016-1gl6? 5 5 8 <br />PERMIT NUMBER I PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br />MUST BE COMPLETED FOR <br />THIS FORM MUSTSHOULD BE ACCOMPANIED BYMIP OT PRLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THN - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. WRGROUND STORAGE TANK RRE�EGff�UUL/�A�1TIOONN/SS(S. THIS FT <br />FORM (6-95) �✓ `�(4e�/,A+ <br />