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STATE OF CAUFCRNIA <br /> QTE'NA—lER RESOURCES CONTROL 30ARO <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY ❑ NEW PERMIT ❑ 3 RENEWAL PEnMl7 5 CHANGE CF :NFORMA7ICN 7 PERMANENTLY CLO5ONSIie <br /> CNE;TEM I nl - IN�cRIM PERMIT a AMENDED PERMIT 8 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> C8A CR FACILITY NAME'NHERE TANK IS;NSTALLEO: 55 -2 F, ` Ill <br /> I. TANK DESCRIPTION CCMPLE i c ALL ITEMS- SPEC:FY,F UNKNOWN <br /> A. OWNEAS TANK 1.0.i I I B. MANUFACTURED 3Y P-1 d <br /> O. DATE INSTALLEO(MMAYIYEAR) 1 I D. TANK CAPACITY !N GALLONS: "OP 7,9 <br /> It.TANK CONTENTS FA-I ISMAAKEO.CCMPLS7E;TEMC. v <br /> A. 171 MOTOR VEHICLE FUEL a OIL g, C to REGULAR I j 3 DIESEL g AVLITICV GAS <br /> UNIEACED r'�-J( <br /> 2 PETROLEUM 80 EMPTY El 1 PRODUCT El Ib PREMIUM A GASANOL 7 METHANOL <br /> UNLEACED a 5 JET,UEL <br /> 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 'HASTE ❑ 2 LEACEO ❑ 9g OTHER (DESCRIBE :N ITEM 0. BELOW) <br /> 0. IF(AA)IS NOT MARXZO. ENTER NAME CF SUBSTANCE STORED C.A-S.S: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY INSOXESA.3,ANOC.AND ALL THATAPPUES'NBOX 0 <br /> A. TYPE OF ❑ I DOUBLE 'WALL 3 SINGLE 'HALL WITH EXTERCIR LINER 95 UNKNOWN <br /> SYS T EM 2 SINGLE WALL A SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> ❑ <br /> B. Tavx I BARE STEEL 2 STAINLESS STEEL 3 FIBERGLASS ElA STEEL CUD 'N!FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 5 CONCRETE 5 POLYVINYL CHLCRICE 7 ALUMINUM ❑ g 100% METHANOL COMPATISLE-WIFRP <br /> (Primary Tani) 9 BRONZE 10 GALVANIZED STEEL c:j 95 UNKNOWN 99 OTHER <br /> ❑ I RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING A PHENCL C LINING <br /> O UN NGI�GR 5 GLASS LINING g UNLINED 95 UNKNOWN ❑ 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— <br /> D.CCRRCSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP a FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHCOIC PROTECTION 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A FABOVEGRCUNCCR U 'FUNCERGAOUNO.30THIFAPPL:CABLE <br /> A. SYSTEM TYPE A U I SUCTICN A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U I SINGLE WALL A U 2 DOUBLE 'NALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U 1 BARESTEELA U 2 STAINLESS Si EL A U 3 POLYVINYL CHLORICE(PVC)A U A FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U g CCNCRETE A U 7 STEEL'N/COATING <br /> A U 8 100y METHANOL CCMpATIBLE'NrFRP <br /> PROTECTION A U 9 GALVANrZFO STEEL A U 10 CATHODIC PROTECT;CN A U 95 UNKVCWN A U 99 OTHER <br /> D. LEAK DETECTION Q I AUTOMATIC UNE LEAK CE-cCTCA 2 LINE TIGHTNESS TESTING I . UL 99 OTHER <br /> NCt,,TORl ING <br /> V.TANK LEAK DETECTION <br /> ❑ I VISUAL CHECK F� 2 INVENTORY RECONCILIATXCN 3 VAPOR MCNfTCRING t AUTOMATIC TANK GAUGING E 5 GROUND'NA'ca MONITCRING <br /> I TANK TESTING ❑ 7 INTERSTITIAL MONITORING D 91 NONE 95 UNKNOWN E:l 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTWATED DATE LAST USED(MOrOAYNR) 2.ESTIMATED CUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING GALLONS I INERT MATERIAL? YES ❑ NO <br /> THIS FCRM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF-WY KNOWLEDGE, IS TRUE AND CORRECT <br /> aPPL:CANT'S NAME GATE <br /> !PWNTEO t SIGNATVH� <br /> LOCAL AGENCY USE ONLY THE STATE LO.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> STATE I.D.>r 6,�6,f;�CC`NTY s JUYRISOICTICN s FACILITx TANK x <br /> PE;mIT NUMBER I PERMIT APPROVED BY/CATE I PERMIT EXPIRATION DATE <br /> FCRM 9 (9.901 THIS FCRM MUST BE ACOO&WANIEO BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS 8EEN FILED. <br /> Fcaaa31 a Ra <br /> r <br />