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STATEDFCAUFOI NIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> sA 17 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B <br /> COMPLETE A SEPARATE FORM FOR LO9 TANK SYSTEM. `'•�^^'" <br /> MARK•ONLY Q t NEW PERMIT t__1 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION � 7 PERMAN :se CN <br /> ONE ITEM C 2 INTERIM PERMIT Q s AMENDED PERMIT ® 8 TEMPORARY TANK CLOSURE Q 8 TANK <br /> OBA OR FACILITY NAME WHERE TANK IS INSTALLED: A Cf_a F'ql_ <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPEC:FYIF:UNKNOWN <br /> A. OWNER'S TANK 1.0.x 44-V 0,4L- P 1 3. MANUFACTURED BY: U 6.t FjI.IOLJ P.1 <br /> C. OATS INSTALLED(MOICAY MEAR) o!S T- a TAW CAPA(,m IN GALLON&; <br /> II.TANK CONTENTS IFA-t ISMARKED.COMPL�TBTIEMC. <br /> L C�t MOTOR V041CLE FUEL a OI. 8, la REGULAR <br /> a DIESELQ 2 PETROLEUM vJ 80 (EMPTY CN et PRODUCT PR <br /> E�MIUM� i a GASAHOL ' =MET14 NC. <br /> Gds <br /> ^ UNLEADED S TET FUEL E'HgN <br /> CI 3 CHEMNcALPRcoucT Q 95 UNKNOWN I� 2 WASTE 2 LEADED 99 OTHER (DESCRIBE IN ITEM 0. 3e.W) <br /> 0: IF(A.1)IS NOT MARKED, ENTER NAME OF SUB&TANCc STORED s C.A.S.x. <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.3 ANO C,AND ALL THAT APPe-ES IN BOX 0 AND E <br /> A. TYPE OF i®.: I DOUBLE WALT. Q 3 SINGLE WALL WITH EX Z IOR LINER Q 95 AWN <br /> SYSTEM %1 '2 SINGLE WALL Q a SECONDARY CONTAINMENT (VAULTED TANK) Q m OTHER <br /> B. TANK ��' 3ARE STEM Q z STAINLESS STEEL Q a FIBERGLASSQ . y;.E---CLAD W!FIBERGLASS REINFCRczC P--AS':c <br /> MATERIAL �_: 5 .ow-lETS 8 POLYVINYL CHLORIDE Q 7 ALUMINUM Q 8 t00%IMErAANCIL COMPATIBLE W:F:;P <br /> (Primary Tank) Q 9 9RCNZE Q 10 GALVANIZED STEM Q 95 UNKNOWN i n OTHER <br /> Q 1 RUBBER LINED C 2 ALKYD LINING i a S OXY LINING QU a PIEi me LINING <br /> C.INTERIOR -� GLASS LINING m uNLwp <br /> LINING 5 I.—.. I_� I i SS UNKNOWN Iu—j 99 OTHER <br /> IS LNI GI MATERIAL COMPATIBLE WITH IOOT.ME-I IANCL? YES� NO_ <br /> 0.CORROSION ❑ s POLYETHYLENE WRAP Q 2 COATING 1 3 vIm- WRAP Q • MERGLAss RE•NFaR= PLAsrc <br /> PROTECTION C 5 CATHODICPROTec-.jCN 9t NONE C„rgg UNKNOWN Q gg GTHF <br /> E.SPILL AND OVERFILL SPILL c wTAwmENT wsTALLm7(YEAR) OVERFU PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGRCUNOOR U IFUNOERGROUNO.SOTHI-A <br /> A. SYSTEM TYPE A U t SUCTION A<q 2 PRESSURE A U 3 GRAVITY A U go OTHER <br /> S. CONSTRUCTION A U t SINGLE WAIL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND AO t 3ARE ST'—= A U 2 STAINLESS STEa A U 3 POLYVINYL CHLORIDE(PVC(A U a FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U a CONCRE IS A U 7 STEEL'AVCOATING A U 8 t00% METHANCL COMPATIBLE W,•FRP <br /> PROTECTION A U 9 GALVANLZE+D STEM A U 10 CATHODICPROTECTION <br /> A U 95 UNKNOWN A U 29 OTHER <br /> 0. LEAK DETECTION C1� AUTOMATIC LINE LEAK DETECTOR Frl UNE TIGHTNESS TESTING <br /> Q MObIf�iING C 99 OTHER <br /> V.TANK LEAK DETECTION <br /> ':2'1 VISUAL CHECK f—I 2 INVENTORY RISCOWMIATION Q 3 VAOOZE MONITORIIG Q A AUTCMA7IC TANK GAUGING I i 5 GROUND WAT=R MCNITCR:NG <br /> Ct es TANK TESTING Q 7 INTErRSTITIALWON(TORNG Q 91 NONE Q 95 WMWIN _� � OTHER <br /> VL TANK CLOSURE INFORMATION <br /> '.ESTIMATED DATE LAST USED(MONOAYNM Z ESTIMATED CAJAN79Y OF 3,WAS TAW FI L�WITH a <br /> SUBSTANCE REM GALLONS INERT MATERIAL? YES <br /> NO <br /> 7W'S FORM HAS 8E .r!COMPS UNDER PENALTY OF FIERJURY,,AND TO THE WT OF MY KNOINLDGF- IS TRUE ANO C.^.RRE::T <br /> APPucmrs NAME <br /> IPAINTIM&S1fiNAtUREt CATE <br /> LOCAL AGENCY USE ONLY THE STATE LO.NUMBER IS COMPOSED OFTHE" R NUMBERS BELOW <br /> cOuNTv x .lualsolCTION a FACILITY x <br /> STATE f.D. ` LLLrI <br /> ?SnMITNUMBEn' J F�4MITAPPROVED BYICATE i PSRMITEXP1RA;.ONOA—,= <br /> =CRM 3 (7.91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUCATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> >:ortccsea�s <br />