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JUL-24-96 WED 07 : 13 PM SCOTT 19163666908 P. 08 <br /> 7-:23-10-96 3.07Ptt FRUio p_ 2 <br /> STATE WATER RE54URCES CONTROL EOAAD ` <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM S «• do <br /> COWLM A SEPARAU FOAM FOR EACH TANK SYSM. •w <br /> MARK ONLY 1 NEN PWIMIT L J 3 RErEWAL Pulu'r a s cwwrw OF INFOis roo 7 064MANEN1lY CL08t0 ON SITE <br /> ONE 011:11 I wTEm u PERMIT Q a AMU40W YERMTT � s TE omptARY TANK CL{7wne H 0 TANK AgMOVW <br /> DBA OR FACU.RY NAK WHERE TANK IS MTALL W. Qd <br /> I. TANK DESCRIPTION Co,ApL m ALJ.ITEMLS- SPECIFY iF UNKNOWN <br /> A.OWNERS TANK r.0,s At 2 A MArVIfFACTuIEO BY: 12 F.QN1 <br /> t7 <br /> C. DATE INSTAU.ED{MWAY/YEAR) 0. TANK CAP=N IM GALLON& � e71�t7 <br /> ll.TANK CONTENTS WA-1 IS MARKEO.C0MPLUTrs fiT.M►C. (—� <br /> A. 1 MOTOR YEMICLE FUEL ❑ • OIL d G 1A REGLW UI AAM L } S DIKE' 1. {AVIATIO.GAS <br /> 1D rMt1wilI YKAMW . GASA)$QL T M9THANOL( j� <br /> Z 1Et'w4L1uA d a EMPTY CD 1 PgCO[!CT to 910600f UVLFMfD f A*T W!L I!MES <br /> Q 3 CFiEA11CAt P1iOWCT ® WUNKNOWN ❑ Z WASTMi p LEADEO B 96 (nom ODE,SCwt6a1MEMO.saOVn <br /> 0. IF(L1)IS NOT MIAAKED.EVrEA NAME OF SUBSTAME 5MNQ C.A.S..: <br /> III, TANK CONSTRUCTION wm ONE rmA oexr ur wxEs A,s.AND c.ANO ALL THAT APpwu w BOX o AND e <br /> A. TYPE OF M DOIIM WALL Q 3 31WAA WAIL WTH EIC SWA UNGA Cl I WRIINAL BLADDER SYSTEM ❑ p uN�NoMmI <br /> SYSTEM f a SINS`(,£WALL -1 SINGIF WAIL IN A VAULT 0 f0 *THEE <br /> 8. TANK 0 1 BARE STEEL ❑ 2 STAINLF$$MEL G 1 FIREAGLAM � t SML CLAO VW FTERGLASS ii"F*0,(`IID PL gTIC <br /> VATERIAL L:j f CO)ICave ❑ i POLYVINYL CIILOWOE 7 ALUMINUM Q 1 10%M&n4ANDL COMI►AT1AlEW/FRp <br /> vrk-l?-k) CD 9 SPQNZE CZ 10 GALw1N¢ED STEEL ❑ If UN**" ❑ N OTHER <br /> G inn RtOR LCJJ I AU88E.v L1NG0 ❑ s ALAYO UW4 ❑ 7 EPDXY LINING a t PSIow-c- LSNwo <br /> UNING OA ❑ s W.Ass vw" ❑ I UANJNEO 96 UNKNOWN ❑ fE OTIIER <br /> COA71NO IS LINING MATERIAL COMPATIgtfi WT7)1 1G0-METHANOL 1 VES— NO` <br /> 0.EXTERIOR ❑i I POLYETHYLVA Waw 2 COATINQ 3 VINYL 111W i IREERGLAss PuiNPOtiGTo pt.ASTC <br /> COI;ROSM <br /> PROTECTION ❑ S CATMIODIC a Ao%CnCN 91 NQ% 95 UN0IOVIN ❑ go me" <br /> puc <br /> E SPILL AND OVERFILL.of ow,7=70L7— <br /> YEs TOVEMLLPMUMON <br /> f TALLiD STRIkiR pWTE YES NO EO{JM OISPE+ISETR�CONTATNreErIT 3 N0 <br /> W.PIPING INFORMATION CIRCLE A IF AWVE 60`104,11`40 04 U IC UNDSIM111 UND.BOTH Is APKICAaUE <br /> A. SYSTEM TYPE A u L SNDflON AD Z AAEs8vw A U 3 L1AAvrft A U a piEcreLE PIPING A Il " OTHEA <br /> L CONSTRUCTION A U I SINOLF WALL Ao r COME WALL A U 3 LAVED 7004N A S tS UNKNOWN A O Ng OTHER <br /> C. MATERIAL ANO A U t i;w STEEL A U 2 SYAWLESS ME& A V 3 POLYVWYL CKQnM tPV41 U f p8t~1GLASS PIPE <br /> CORROSION A U s ALUMINUM A U E CONCAETE A u T MEL VW COATING A V E 109%meTHMIOL COMPATIBr.E wmar <br /> PAM"ON A U 9 d94VANIZE0 STEEL A U 10 CATHODIC PRA)TOCTION A U IS UNKNOWN A U N OTmR <br /> 0. LEAK DETECTK}N L 1 4 uw t&" g?t U4 txga E5i a oarrnuow NtsaaTx e f mule f wra�*e a.► O p9 vsnrys <br /> ,Q�4_ ,..IIID YQN,PIwa a 0 <br /> V.TANK LEAK DETECTION <br /> d 1 mm- <br /> Va*L C+<ECK ❑ s Y [� s v {� • nG LANK S MONITO WATER 6 rfa L TAr+K <br /> 7 M/catmntJOUGS MTERSTITSAL = E sm Q s WOTANCY MANUAL O 10 MOMMY TANK 0 tti t7NIapWN I�3 N OT)+�NERQ <br /> VI.TANK CLOSURE IMFORMAMON nnumm cL.osuRE Ed.RLAM <br /> I.ESTIMATED OATS LAST UU01MIO1flIAYlYR3 S.wrMATEO OUMr71TV OC 3,WAS TANK 14LLED MTN <br /> SUBSTANCE REMANNNQ GALLONS INi1tT MIAT%lM 7 YES Q NO <br /> THIS FOPM NAS 86c- t COMPLLPPeo UNDEP PENAL 7Y OF EMU"AN0 TO 7WE BEST'OF My KNOM XF-is TRUE AND comRECT <br /> TISK Gt slCr+rt511RNAME <br /> Al DATE <br /> -J q� <br /> LOCAL AGENCY USE ONLY THE STAIrs LD,NUM VER is COMFOOSED OF THE FOUR NUMMU BELOW <br /> COUNTY t JMSOMC170N f FACILM s TANK r / <br /> STATE LDA 7� <br /> � �..� X21 � � ?� v ��, <br /> PpMR NUMBER "Fur N+PR6VE0 3.f uvE Pr RILIIT F7V�RATION C7ATre <br /> 7 3� <br /> THIS FOAM MUST are ACCOMPARIW BY A PST APPLICATKIN.POW A.VRLUS A CURREW FOMA A HAS OEW P4&L PM C MIST BE COfauTW FORALj ATIa N3 76 FORM <br /> SHOULD BE ACCOMPANIED BY A PLOT PIAN.FILE TNS POW WITH THE LOCAL AGENCY WUSANWIM 7RE WWFRGRQUNQ STORAGE TANK MGUI.ATM3 <br />