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• 4UUw P4 <br /> r� cri <br /> STATE OF CALIFORNIA `- <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B es ��. D <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM 2 INTERIM PERMIT a 4 AMENDED PERMIT a 6 TEMPORARY TANK CLOSURE a 8 TANK REMOVED <br /> i <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ,c}�A LS, <br /> I, TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# B. MANUFACTURED BY: AO <br /> C. DATE INSTALLED(MO/DAY YEAR) n D. TANK CAPACITY IN GALLONS: <br /> "V6 0 901 <br /> II:TANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. REGULAR !!� <br /> 1 MOTOR VEHICLE FUEL 4 OIL 8. C. 1aUNLEADED 3 DIESEL E 6 AVIATIONGAS <br /> A 2 PETROLEUM .7 80 EMPTY 1 PRODUCT 1b PREMIUM 4 GASAHOL r 7 METHANOL <br /> UNLEADED 5 JET FUEL -J <br /> 3 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D_ BELOW, <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E <br /> 7Y1 <br /> A. TYPE OF 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> /�V_ <br /> SYSTEM _j 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> 1 BARE STEEL2 STAINLESS STEEL 3 FIBERGLASS U 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK <br /> I e n I S CONCRETE n 6 POLYVINYL CHLORIDE 7 ALUMINUM u 8 1001/ METHANOL COMPATIBLE W/FRP <br /> h,,.TERIAI -_ �-- <br /> (PrimaryTank) 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN C 99 OTHER <br /> j 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.iNlERIOR JI 5 GLASS LINING O 6 UNLINED O 95 UNKNOWN 99 OTHER <br /> LINING -- <br /> IS LININGMATERIALCOMPATIBLE WITH 100% METHANOL? YES V NO_ <br /> U.CORROSION L� 1 POLYETHYLENE WRAP E:] 2 COATING 3 VINYL WRAP Der4 FIBERGLASS REINFORCED PLASTIC - - <br /> PRO fECTION _J 5 CATHODIC PROTECTION 0 91 NONE a 95 UNKNOWN 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION ACU 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL AD DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL CO gTIBLE WiFRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A(a9 OTHER�V <br /> I:Fi5l 11 IAL <br /> L). LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR [:] 2 LINE TIGHTNESS TESTING 3 INON(TORING E] 99 OTHER <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK ^ 2 INVENTORY RECONCILIATION O 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING <br /> ^�7 6 TANK TESTING 7 INTERSTITIALMONITORING CI 91 NONE a 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> I.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES 0 NO <br /> SUBSTANCE REMAINING GALLONS <br /> IN MATERIAL? <br /> THIS FORM HAS BEEN COMPLETED UNDER PENA TY OF PERJURY,Allp TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> (PRINTED 8 SIGNATURE) <br /> AaJ_ A�� <br /> 1' - <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# UO <br /> STATE I.D.# s (a �v 0 w� /�7 <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> -41aa1�I � 6.R5 <br />