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STATEOFCAUFORMA . <br /> STATE WATER RESOURCES CONTROL BOARD <br /> e'.4 1i6ro <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> COMPLETE A SEPARATE FORM FORE CH TANK SYSTEM <br /> MARK'ONLY : 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION r7 7 PERMAN ED ON E 1f� <br /> ONE ITEM 2 INTERIM PERMIT d AMENDED PERMIT 6 TEMPORARY TANK CLOSURE E] 8 TANK <br /> r <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: AQc-o 'F'AG- N10. 0648 d <br /> t <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK 1.0.9 Ul.LL--e I B. MANUFACTURED BY: u I'L V,�,-a o w If <br /> C. DATE INSTALLED(MO/DAY/YEAR) Q S _ / (l I 0. TANK CAPACITY IN GALLONS: �Q <br /> II.TANK CONTENTS IFA-11SMARKED.COMPL.ETEITEMC. <br /> t MOTOR VEHICLE FUEL d OIL a REGULAR <br /> A. B. C. I- 3 DIESEL 6 AVIATICN GAS <br /> UNLEADED <br /> d GASAHOL <br /> 2 PETROLEUM 80 <br /> EMPTY -1l1 PROOUCT lb PREMIUM 7 METHANOL <br /> -, UNLEADED I 15 :ET FUEL <br /> (� 3 CHEMICAL PRODUCT C:l 95 UNKNOWN ❑ 2 WASTE 2 LEADED � gg OTHER (DESCRIBE .N ITEM 0. BELOW) <br /> 0: IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.8: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C.AND ALL THAT APPLIES IN BOX D AND E <br /> ! A. TYPE OF O I DOUBLE WALL U 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM <br /> e'? SINGL:WALL d SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> S. TANK �1 BARE STEEL C 2 STAINLESS STEEL 3 FIBERGLASS U d STEEL CLAD W/FIBERGLASS REINFORCED PIaST:C <br /> MATERIAL ❑ 5 CONCRETE J 6 POLYVINYL CHLORIDE 7 ALUMINUM U 8 100% METHANOL=MPATIBLE W/FRP <br /> (Primary Tank) 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN I 99 OTHER <br /> I RUBBER LINED L_� 2 ALKYO L INING i 3 EPDXY LINING d PHENOLS LINING <br /> C.INTERIOR <br /> LINING 5 GLASS UNING E�6 UNUNED 95 UNKNOWN 99 OTHER <br /> �- <br /> IS LINING MATERIAL COMPATIBLE WITH 1007.METHANOL? YES_ NO <br /> D.CORROSION u 1 POL'�IYLENE WRAP F7 2C.^ATING Q 3 VINYL WRAP d FIBERGLASS REINFORCED PLAS,.0 <br /> PROTECTION 5 CATHOOICPROTECTION ' 91 NONE �_2(A5 UNKNOWN J 99 OTHER <br /> ! G SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) ! <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNOOR U IF UNDERGROUND.BOTH IF:APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A(D 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> 3. CONSTRUCTION Ao t SINGLE 'HALL A U 2 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 d FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL'ANCOATING A U 3 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION AUTOMATIC UNE LEAK DETECTOR r� UNE TIGHTNESS TESTING ❑ MONITORING I- 99 OTHER <br /> V.TANK LEAK DETECTION <br /> I ;e'1 VISUAL CHECK 2 INVENTORY RECONCIUATION 3 VADOZE MONITORING s AUTOMATIC TANK GAUGING 5 GROUND WATER ER MONITORING <br /> j > 5 TANK TESTING ❑ 7 INTERSTITMALMONITCRING ! 91 NONE 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> aTIMATED DATE LAST USED(MO/OAY/YR) 2.ESTIMATED OUANTITY OF I WAS TANK FILLED WITH I <br /> YES NO <br /> SUBSTANCE REMAINING GALLONS ! INERT MATERIAL? <br /> THIS FORM HAS BEEN COMPL, i tD UNDE.R PENALTY OF P- JURY.AND TO THE SPST MY KNOWLEDGE1S TRUE ANO CaARECT <br /> APPLICANTS NAME DATE <br /> !PRINTED 6 SIGNATURE) <br /> Tz - Z•Zl -�•t � . � <br /> LCCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OFTHE FOUR 11116MBERS BELOWI�-/ - <br /> e, f COUNTY x JURISDICTION x FACILITY x TANk x <br /> STATE [.D. t C I I ''!T I I I G�ll)(, (�J•��4 <br /> HERMIT NUMBER i PERMIT APPROVED 8Yf0ATE PERMIT EXPIRATION CATE <br /> ;CRM 3 (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FOROCI48-AS <br />