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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD t <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B <br /> COMPLETE A SEPARATE FORM FOR EYN TANK SYSTEM. c•`"""� p� <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT I 5 CHANGE OF INFORMATION (� 7 PERMAYC'N ON <br /> ONE ITEM (I J 2 INTERIM PERMIT d AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TAN RE <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: to rzt-O 'F'qL rLv, o SL•18 2 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.0.0 ;Z UAL-V- i S. MANUFACTURED BY: <br /> C. DATE iNSTALLED(MO/OAYNEAR) ds/_/�� 0. TANK CAPACITY IN GALLONS: 4 CCO <br /> IV <br /> II.TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. <br /> MOTOR VEHICLE FUEL 4 OIL �y REGiJLAR i 3 DIESEL f- <br /> A. �1 B. C. <br /> L� U ETILA O i1 4 DIESELGASAHL r- 6 AVIATICN GAS <br /> C 2 PETROLEUM (� 60 EMPTY Cil-t PRODUCT C lb PCIEMIUM � � 7 METHANOL 5 :ET FUEL <br /> I_ 1 CHEMICAL PRODUCT 95 UNKNOWN 2 WASTE 2 LEADED '1-! 99 OTHER (DESCRIBE IN ITEM 0. 3E1.01N1 <br /> 0. 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.S.AND C.AND ALL THAT APPLIES IN BOX O AND E <br /> A. TYPE OF = 11 DOUBLE WALL 3 SINGLE WALL WITH 0(TERICR LINER I� 95 UNKNOWN <br /> SYSTEM =-f"2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> 3. TANK � ' 3ARE STEEL 1-1 2 STAINLESS STEEL j_j 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLAST;C <br /> MATERIAL (_: 5 CONCRETE 6 POLYVINYL CHLORIOE ❑ 7 ALUMINUM 8 100% ME.HANOL COMPATIBLE W/FRP <br /> (Primary Tank) 9 3RCNZE 10 GALVANCZED STEM- I j 95 UNKNOWN j� 99 OTHER <br /> 1 1 RUBBER LINED 2 ALKYO LINING j j 3 EPDXY LINING 4 PHENCUC LINING <br /> O.INTERIOR r- <br /> LINING �� 5 GLASS LINING �j�"o UNLINED 95 UNKNOWN 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100!METHANOL*? YES_ NO_ <br /> D.CORROSION 1 POLYETHYLENE WRAP 2 COATING = 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHOCICPROTECTION 91 NONE I R15 UNKNOWN 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV. PIPING INFORMATION CIRCLE A IFABOVEGRCUNOOR U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A02 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> 3. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND AG)1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORICE(PVC)A U 4 F113FRGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEa-1..W/COATING A U B 100 METHANOL CCMPATIBLEW/FnP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION C 1 AUTOMATIC UNE LEAK DETECTOR C-f UNE TIGHTNESS TESTING C vONRORING ❑99 OTHER <br /> V.TANK LEAK DETECTION <br /> j�1 VISUAL CHECK G 2 INVENTORY RECONCILIATION 3 VACOZE MONITORING C�] d AUTOMATIC TANK GAUGING a 5 GROUNO WATER MCMTCRING <br /> I%6 TANK TESTING C 7 INTERSTITIAL MONITORING 91 NONE 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1._STIMA.cD DATE LAST USED(MO/OAY/YR) I 2.ESTIMATED OUANTITY OF I 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES NO <br /> THIS FCRM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND -10 THE BEST OF MY KNOWLEDGE_, IS TRUE AND CORRECT <br /> APPt:CANrs NAME { DATE <br /> (P41NTED 6 SIGNATUFE <br /> >. �c.Ia t-1-- Z•Z •R Z. <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NU ERS BELOW I'✓ <br /> Ccs¢ COUNTY x JURISDICTION x FACILITY x TANK <br /> STATC I.D. 11 ( I l z i / I/ rI.1�7�IC)I7 I <br /> PERMIT JLM6cR PERRMITAPPROVEDBY/OATE PERMIT EXPIRATION DATE ^ <br /> FORM 3 (7.311 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FLED. <br /> FCRG=91S <br />