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STATE OFCAUFORN IA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B <br /> COMPLETE A SEPARATE FORM FORJXHTANK SYSTEM "`• ^^'^ <br /> MARK'ONLY 1 NEW PERMIT p 3 RENEwAI. PERMIT 3e 5 CHANGE OF INFORMATION 07 PERM ON S7 <br /> ONE ITEM p 2 INTERIM PERMIT p 4 AMENDED PERMIT F7 8 TEMPORARY TANK CLOSURE pa T E <br /> OBA OR FACILITY NAME WHERE TANK IS INSTALLED: AeL0 �' taQ, OS 4 <br /> I. TANK DESCRIPTION coMPLETEALL iTeAs-sPSC:FYIFUNKNOWN <br /> A. OWNER'S TANK I.O.s 5 8. MANUFACTURED BY• U$A Kj,.L O Int 1J <br /> C. DATE INSTALLED(MO/OAYroEAiii OS - �(� I M TANK CAPACITY IN GALLONS: SSD <br /> II.TANK CONTENTS IFA•t ISMAAKED.c,cmftm r Ac. <br /> A Q t MOTOR VEHICLE FUEL prt'a OI. t 8, C, p to REGULAR 3 OIESGL t- <br /> J a AVIATIONGAS <br /> Q 2 PETROLEUM Q 90 EMPTY p I PRODUCT ® t®PREMIIUMD 4 GASAHOL <br /> Ip T METIaANOL <br /> UNLEADED 15 JETFUEL <br /> Q 3 C HEMICAL PROOUCT p 95 UNKNOWN py1--2 WASTE p 2 LEADED X99 OTHER (OESCRISE IN ITEM 0. 8ELOW) <br /> 0. IF(A.t)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED V sS 6® A•ICr1 o g- Q t,,.. C.A.S.•: <br /> Soo 41 Co I <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.9.AND C.AND ALL THAT APP(.IES IN BOX 0 AMC E <br /> A. TYPE OF = t DOUBLE WALL ® 3 SINGLE WALL WITH EXTERIOR LINER Q 95 UNKNOWN <br /> SYSTEM C2-2 SINGLE WALL Ip a SECONDARY CONTAINMENT (VAULTED TANK) p N OTHER <br /> B. TANK !-'" t BARE STEEL p 2 STAINLESS STEEL ® 3 FIBERGLASS Q a STEEL CLAD w/FIBERGLASS REtNFORCe'0 ELAS TTC <br /> MATERIAL Q 5 CONCReTs. p 8 POLYVINYL CHLORIDE Q 7 ALUMINUM Q 8 100N.METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) Q 9 3RONZE Ip 10 GALVANIZED STEEL p 95 UNKNOWN p 09 OTHER <br /> p t RUBBER LINED p 2 ALKYD L:.NwGa p 3 EPDXY LINING p 4 PHENOL:C LININ G <br /> C.INTERIOR Q 5 GLASS LINING a UNLINED Q 95 UNKNOWN Q 99 OTHER <br /> LINING <br /> IS LINING MATERIAL.COMPATIBLE WITW 1009E uETHANIOL? YES_ No <br /> 0.CORROSION �I I I POLYETHYLENE WRAP Ip 2 COATING p 3 VINYL WRAP Q 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 cATHOOO PROTECTION p; si NONE ptr5 UNKNOWN r� oTI�ER <br /> l�. <br /> E.SPILL AND OVERFILL SPILL=NTANmerr wvAum(YEAR) OVERFILL PREVENTION EG`IIPmerr INSTALLED(YEAR► <br /> IV.PIPING INFORMATION CIRCLE A VASOVEGROUNOOR U tFUN10ERGROUNO.3OTHiFAPPLICABLE <br /> A. SYSTEM TYPE A U I SUC7ICN A U 2 PREMAE A u 3 GRAVITY A(o 99 OTHER <br /> S. CONSTRUCTION A U t sIVGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN Ao W OTHER <br /> C. MATERIAL AND A U I BARE STErEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CKORIOE 0nkfgA U 4 FIBERGLASS PIPE <br /> CORROSION A u s ALUMINUM A u S CONCRETE A U 7 STEEL W COATI G A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEM. A U t0 CATHCOOPROTECTION A U 95 UNKNOWN A U�ss OTHER A�LQ.1C <br /> 0. LEAK DETECTION p 1 AUTOMATICLIQLEAKOE'iECTOR p 2 LINETIGHTNESSTESTING p s y nO p-egs OTHER i-I <br /> V.TANK LEAK DETECnON <br /> ,-1-1 VISUAL CHECK ® 2 INVENTORY RECRNICIZIATTON 3 VADOZEMONITORING Q A AUTOMATIC TANK GAUGING 1-7 5 GROUND WATER MONITORING I <br /> f 7.ra TANK TESTING Q 7 NTERSTTTtALMONITORNG Q 91 NONE Q 95 UNKNOWN p 9s OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> t._STIMATED DATE LAST USED(MO/OAYKR) 7-ESTIMATED OUANTTTY OF 2 WAS TAMC FILLED WITH YESp <br /> SUB No <br /> -- A GALLONS VERT MATERIAL.? <br /> TN1S FORM HAS B�COMPLE ED UNDER PENALTY OF PERJURY.AND rO THE BEST OF MY KNOWGEDGF_ IS TRUE AND CORRECT <br /> APPL CRINIS NAME OATS <br /> Ia,aarlo a 3�swtvREt <br /> Ems+ Q Z•ZI-Cal, <br /> LOCAL AGENCY USE ONLY THE STATE LD.,VUMSE.R IS COMPO OFTHE FOUR NUMBERS aELOW <br /> _ COUNTY x JURISOICTICIN s FACILITY x TANK a , <br /> STATE <br /> i= I.D.T <br /> n <br /> PERMIT.NUMBER + PeRMITAPPROVED 8YtOATE I PERMITE)MRATIOINDATE <br /> ( <br /> -ORM 3 (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> �� Foaam.+9-as <br />