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STATE OFCALIFORNA a <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B :'?�a�'j'�'/"c ►2i <br /> COMPLETE A SEPARATE FORM FOR TANK SYSTEX <br /> MARK'ONIY Ci 1 NEW Pc-SMIT Q 3 RENEWAL PERMIT ; s CHAWM OF !NFORMATKSN Ir7 7 PMIMANY C c0 ON <br /> ONE ITEM 2 INTERIM PERMIT ® a AMENDED PERMIT 6 TEMPORARY TAMC CLOSURE � 6 TAN RE 0 <br /> OBA OR FACILITY NAME WHERE TANK IS INSTALLED: 'A$ C.O Ffzw, K jo. p S4 8 Z h . <br /> /17 <br /> L TANK DESCRIPTION caMPLi6 ALL nmis-sPMc:FY IF UwNOwN <br /> A. OWNERS TANK I.O.• 2-U,AL-tZ j 8. MAMOACTURE0 8Y: <br /> r DATE INSTALLED(MCIOAYIYEAR) OSI-1&4o p 0. TANK CAPACITY IN GALLONS: 44 Oco <br /> 11.TANK CONTENTS IFA-1 IS MARKED.COMPLETErrEMC. <br /> MOTOR VEFIIC..2 FUEL s 00. REGULAR i f <br /> L I ® g C. CUNLEACEp 3 DIESEL o avtATICN GAS <br /> t C GASAHOL 2 PETROLEUM (� 30 EMPTYCyrS PRODUCT ,bPgEM&/N1 j 7 uET'.+�WCL <br /> u <br /> i_s 3 CHEl1AICAl?ROCUCT 95 UNKNOWN 2 'HASTE Q UM SACED I I 5 :Er�JEL 2 L.AOED 99 OTHER (OESCRISE IN ITEM O..BELC,.n <br /> 0: IF(A.I)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.s: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BoxEs A.&ANo c.AND ALL-,1+AT APPLIES IN aox 0 ANO E <br /> A. TYPE OF L-_: It ABLE WALL a SINGLE WALL wITN ---frER1aR LINER 95 UNKNOWN <br /> SYSTEM =✓� 2 SINGLE WALL Q a SECONDARY CCNTAINMENT (VAULTED TANK) � N OTHES 1 <br /> S. TANK 3ARE sT '� (i 2 srAtNlsss STEEL j� a FiaERGlass . STE=LLcLAO wi FIBERGLAASS RE;NFCRcFo PLAS':C <br /> MATERIAL I__ 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM a t00x METHANOL COMPAT18LE WIFnP <br /> (Primary Tank) 9 3RCNZE 10 GALVANIZED STEEL 1 j 95 UNKNOWN 1-1 99 OTHER <br /> t RUBBER LINED 2 ALKYD LINING C 3 OXY LINING !1 a PHENCLC LINING <br /> C.INTERIOR I 5 GLASS LINING =w 6 UNLINED LINING - f—i 95 UNKNOWN � N OTi+c'R <br /> IS LINING MATERIAL COMPATMUE WITH 100%METI4AN OL? YES_ NO_ <br /> 0.CORROSION t POLYMTHYLENE WRAP (� 2 COATING = 3 VINYL WRAP a RRERGLASS REINFORCED PLASTIC <br /> PROTECT'ICN 5 CATHDOicPROTEcnoN 91 NONE i�5 UNKNOWN 99 ori ea <br /> E.SPILL AND OVERFILL SPR(.CONTAINMENT'INSTALLED(YEAR) OVERFILL?REVENTm EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRc:E A IF ABOVE GROUND OR U IF UNIXAGROUNO.BOTH IF c <br /> A. SYSTEM TYPE A U I SUCTION U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> 3. CONSTRUCTION A(@ I SINGLE WALL A U 2 OOU81.E WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 CTHER � <br /> C. MATERIAL AND A(U) t AAE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL 04LCR (PVC)A U a FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 $TEEL'AIC OATIN%'a A U 6 100% METHANOL CCMPATI8LE W/F:P <br /> PROTECTION A U 9 GALVANRED STEEL A U IO CATHCOIC PROTECTM A U 95 UNKNOWN <br /> A U 99 OTHER <br /> 0. LEAK OETECTION =w'-: AUTOMATICUINELEAKOETECTOR C�LINETIGtTNESSTESTWG Q dbNtTCR=MG ❑99 OTHER <br /> I <br /> V.TANK LEAK DETECTION <br /> I VISUAL CHECK ❑ 2 INVENTORY RECONCIJATiON 3 VAOOZE MONITORING ❑ ♦ AUTCMATIC TANK GAUGING 5 GROUNO WATER MCNITCRING ! <br /> /8 TANK TESTING C 7 INmRsTmALmoNITDRm ® 91 wi4e I� 95 UAAMWN r 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> t.23TIMA�c0 CATE LAST USED(MO/0AYAYR) 2.ESTIMATED OUANTITY OF <br /> I 3.WAS TANK FIIe <br /> LED WITH YES NO <br /> SUBSTANC S REMAINING GALLONS MELT MATERIAL? <br /> HIS FCRM HAS SEEN CCMPL— crJ' UNDER PENALTY OF PET' IURY,AND i� THE NEST OF AfY KNOWL DGi IS SUE ANO CCRRECT' <br /> APP!:CANTS NAME <br /> !Pc"mrW&SIGNATURO <br /> ti <br /> LCCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OF THE FOUR NU ERS BELOW <br /> sTATE 1.D.Y <br /> dcr y COUNTY x JURISDICTICN s FACx1TY s TANK x <br /> t�= ' 12Ii 1� ! I iI f iZ!% i It h_-I�7IIC�17. '1�Z. I <br /> ?M�MIT.:L«8fie+ j PERMIT APPgOVED aYADAr- ! PERMIT EXPIRATION DATE ! <br /> CPM 3 (7-911 TF(IS FORM MUST 3E ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS 8EF-4 FILET?. <br /> FcRma:ss <br />