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• 44�- ^; <br /> STATE OFCAUF40MRA �- <br /> STATE WATER RESOURCES CONTROL BOARD ,�.�? <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ; ) <br /> COMPLETE A SEPARATE FORM FOR CH TANK SYSTEM. <br /> MARK'ONLY f_1 1 NEW PERMIT 1-7 2 Re F-wAL PEr;Mir 5 (MANGE OF INFORMATIONEl 7 PERM -fl ON E <br /> ONE ITEM 2 INTERIM PERMIT (77 A AMENDED PERMIT ® 6 TEMPORARY TANK=SURE F—I 3 TANK <br /> OBA OR FACILITY NAME WHERE TANK IS INSTALLED: RQ.G.q SAL. Njo. 0S148 <br /> I. TANK DESCRIPTION ccMp-sT,--ALL rreus-sPEc:FYIFUNKNOWN 71 <br /> A. OWNEFrS TANK L 0.0 ,-UWA;--e I 3. NANUFACTUAEO 3Y• <br /> • u n1I��lO Is,t K.1 <br /> C. OATS INSTALt,D(MOADAYIYEAR) S l- 4 ! 0. TANK CAPACITY IN GALLONS: <br /> II.TANK CONTENTS IFA•I ISMARKED.COMP C-Te TEMC. <br /> AL EZ- 1 MOTOR VEHICLE FUEL A OLI 3 a AEGULAR 2 DIESEL �' <br /> C �- UNLEADED I_ 6 AVIATiC.V G 1S <br /> -j a GASAHOL <br /> 2 PETROL-:UM I� ac SIPTY �4�, PRoOUCT F I ro PREMI1 7 I.IETHANOL <br /> j H SICAL PRODUCT ® 95 UNKNOWN a WASTE I LUNLEADED ! 5 :ET FtiEL <br /> L. 2 F-AGED � <br /> 2 Cgg OTHER (OESCRIe tN ITEM 0.'SELOWK <br /> 0. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.9: <br /> III. TANK CONSTRUCTION uARKONE rTEMONLY IN80XE5A.a.AND c.AM ALL THATAPPILSS IN SOX 0 AND E <br /> A. TYPE OF = I OCUSLE WALL 3 SINGLE WALL•MTN EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM =o42 SINGLE WALL Q A sECoNoARY coNTAINMENT (VAULTED TANK) 99 OTHER <br /> 3. TANK l t'i't BARE STEEL C 2 STAtNL 3S STEM=eM s M8E.aGL ASS a S, -ICLAD WA MSERGLASS REINFORCED P'-AS-..0 <br /> MIATERIAL 5 C0NCRETE L� 6 POLYVINYL C14LORCE 7 ALUMINUM u 3 100%METHANOL.^..'•MPAT18LSWAFnP <br /> (Primary Tank) ; 9 3RCNZE rj t0 GALVANIZED STEEL r I 95 UNKNOWN I I 99 OTHER <br /> 1 RUBBER LINED jri 2 ALKYO LINING !1 3 EPDXY LNING A PHE CI.n. LINING <br /> C.INTERIOR <br /> LINING ��I 5 GLASS LINING =,('13UNLINED 11 95 UNKNOWN Q OTHER <br /> IS LINING MATERIAL COMPATIBLr WITH 1007.METHANOL? YES— NO_ <br /> 0.CORROSION I ''OL.-wLENE WRAP F-1 2 CCATING 2 VINYL.WRAPI�j a FF8ERGLASS ;;ENFORCED PLAST.0 <br /> PROTEC.'10N 5 CATHcctcPROTECTIOIN !�; 91 NONE UNKNOWN J 99 OTHER <br /> i SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL?REVENTICN ECUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION C:RCLE A IFA8CVEGROUNOOR U IFUNDERGROUNM 3OTHIFAPPL.N;A8LS <br /> A. SYSTEM TYPE A U I 3UOTICN A727 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> S. CONSTRUCTION a I swGLE'MALL A U 2 OOUSLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND AID 1 BARE STEEL A u g STAINLESS STEED. A U 3 POLYVINYL CHLORIDE PIC)A U A FIBEAGi.ASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONQWTE A U 7 STEEL AfICOATING A U 3 100%METHANOL COMPAT38LE W/FnP <br /> PROTECTION A U 3 GALVANIZED STEEL A U 10 CATHCOICPROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> 0. LEAK OETECTIO N C� AUTOMAT)C LINE LEAK OE-.WM. R g72 LINE TIGHTNESS TESTING C7 ffTEISlIfIAL <br /> MQN1r0RtNG i1 99 OTHER <br /> V.TANK LEAK DETECTION <br /> I i It VISUAL CriEt'.3C Q 2 INVENTORY Fge=N IUATION 13 VAOOZE MONITORNK3 ® A AUTOMATIC TANK GAUGWG 1-7 5 GROUND WA-...R eR MONITORING <br /> J TANK TES'.!NG C T IVTEs37iiTALMo{NrrOAINa !II 99 SNE 135 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.=STIMATED DATE LAST USa^O. (MC40AYAYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK F!U--7D WKTH <br /> SUBSTANCE RBIAININIC3 GALLONS I INERT MATERIAL? YES s <br /> 7-P!1S FORM HAS 3E:rV CCA4FLE-1cD UNDE.7 PENALTY of?-E3JURY.AND TO 774E sEST MY ifNOWLFDGc,IS TRUE AND CCRRECr <br /> APP�rCANTS NAME <br /> ;PRINTep d StGNw1VRl5 OATE <br /> LCCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OFTHE FOUR X&BERS BELOW LI <br /> oxlw COUNTY 9 URlSOIC ,CN x FAC2jTY x TAN s (J� <br /> STATE l.D.Y /, �� a I I i '7 ! GIr Ai c, � A <br /> 'ERMIT Vt:MBER I i PERMIT APP40VE0 3YlOATE : ?c eMIT EXPIRATION CAS c <br /> =CRM 3 (7.91) T HIS FORM MUST 3E A=MPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BE=N FILED. <br /> xKaocus..:S <br /> // v <br />