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• r+ t G Vr `AL lFOt:,4IA WATER RESOURCES CONTROL BOARD <br /> FORM 'B': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY El 1 NEW PERMIT 3 RENEWAL PERMIT <br /> ONE ITEM I E12 INTERMPERMIT 0 5 CHANGE OF INFORMATK)N <br /> El4AMENDEDPERMIT 07 PERMANENTLY CLO TANK <br /> FACILITY/SITE NAME.WHERE TANK I4 INSTALLED; ❑6 TEMPORARY TANK gOSU1K <br /> 8 TANK REMOVED it <br /> I. TANK DESCRIPTIONARM TANK-YE4 <br /> COMPLETE ALL ITEMS-IF UNKNOWN—C 'C <br /> � NO <br /> A_ OWNERS TANK IDK 40 SPECIFY <br /> 1 O <br /> C. YEAR INSTALLED -------- B. MANUFACTURED BY p <br /> TANK <br /> TY <br /> N GALLONS <br /> I1. TANK CONTENTSIF(A_1),14 MARKED,COMPLETE ITEM C.IF(A./D,3 NOT MARKIEDi COMPLETE ITEM D. <br /> F � <br /> A 0 1 MOTOR VEHICLE FUEL E]2 PETROLEUM <br /> 0 3 CHEMICAL PRODUCT A OIL <br /> © r� C 0 1 UNI EA ED 0 2 LEADED J DIESEL N <br /> 5 HAZARDOUSEl EJ 95 1 PRODUCT A GASAHOL 1:15 JET FUEL <br /> UNKNOWN 0 6 AVIATION GAS <br /> D. IF NOT MOTOR VEHICLE FUEL, 6D EMPTY ENTER NAME OF ❑ 2 WASTE � ) METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW( <br /> HAZARDOUS SUBSTANCE STARED 6 CA.S.It <br /> •III. TANK CONSTRUCTION MARK ONE ITEM O11LY IN BOR A B C.A p <br /> A TYPE of /� Q I DOUBLEWAf 3 SNGtE WAl ED <br /> SYSTEM MIH EIEN7 #PCA ❑9S LWAOM/ <br /> 2 SHGE WAl1BU �/SECCYONN OGRANMEM <br /> 1 STEEl/FDN ❑99 DTIER <br /> S. TANK <br /> lS ❑S FTE 6 ST �OROf ❑; ClAss 1 STEEL CLAD w/EIBERDIASS flEHfORCFD RASTIC <br /> 09BRONZE 1—kLVAMZEDSEfl 0 ❑ti00f1 WRLAN0.LUFATBLERP <br /> %UxNU9N 0 99 DTHEfl <br /> G INTERIOR El1 M'BBFR tFgI E]2 AU(YD LMIM �J EPO%Y IxKNG <br /> L1N1 //_ ❑5 GASS LO IC 0 L Lam. ❑A RE9A9UC,,NG <br /> YJ 0 SL"C WTUW COWATELE WTM 100%WTIMNDL El 95 UIKNt m <br /> D. CORR i RxYETNBIEWRTI YES El NO El 99 OTHER <br /> El2TARORASRWT <br /> %TOTE 0 5 UTMODID R90TECTICN �9I NDNE ❑3 VNTI WRV 0 E TIBEROIARIEIEDRLS/ELASTIC <br /> IV. PIPING INFORMATION a ❑ %uwaAN El 99 OTHER <br /> RCIE A IFABOVE GROUND, U IF UN <br /> A. SYSTEM TYPE A U 1 SUCTION �ERO'R�/ND,BOTH IF APPL/CAD� <br /> A U 2 PRESSURE <br /> IL Comm <br /> A U 1 WA1.LtD A U 2 DOUBLE WALLED A U 3 UNED TgENCN A U OTHER <br /> STEEU,,ON U M UNKNOWH <br /> G MATERIAL '�/ A U ■ Au1rANLAI A U ■C ESTEEI A U ) � mPlORIDE(PVC) A U A RBEMRASS p,pE OTHER <br /> DALVAMZEDSTEg A U MUryKNOWN CUp W/FIV A U t '0 <br /> A U 99 OTHER METHANOL COMPATIBLE FRP <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY.OR S FOR SECONDARY,A PRIMARY <br /> 1 VtSPR CHECK ► t 2 KNENT01N LEAK DETECTION SYSTEM MUST DC CIRCLED. <br /> In 1t • PREGSIOH TFBitAIO I • T PRESSURE TFSTIRECONCIUATKMI I ■ 3 VADOSE WELLS I t A EIECTROHC AgWTOR • ■WNOWNy <br /> /� I • t, NONE % GROUND WATER MONRORIND WELLS <br /> 'BVI. INFORMATION ON TANK PERMANENTLYI ■ • • °' OTHER- <br /> MATED OATEI LSI CLOSED IN PLACE <br /> I/ LrsEn tMo/YR( <br /> j-C srnurED ouANTm of <br /> ANC:REMAINING IN AS TANK FILLED WITH <br /> THIS FORM HAS BEENCpM OALLOH■ 2 RT MATERML2 DYES 0 FID <br /> PL.D A& UNDER PENAL TY OF PERJUf7Y,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT. <br /> APPLICANTS NAAA=( MPI-EtBKiNATL1gET <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> JURISDICTION It <br /> # , / , <br /> AGENCY# FACILITY to yy <br /> `, YZ�7 �-T TANK ID# <br /> Z d WCK AYCNC1f/ApLFTY D t i <br /> r NAw <br /> P74M UWAS"- ♦ .; 9 PNOom 0 WITH AA"COO# <br /> 3 p jKCA P■ALK1f <br /> My <br />