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STATE OF CAUIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD f ry Y <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B <br /> COMPLETE A tEPAnATE FORK!F0I4 riN TANK SY5TENL <br /> MARK ONLY ! NEW PERMIT 1 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C',=-0 ON SITE <br /> ME REM 114TERIM PERMIT 4 AMENDED PERIAIT II TENPOWY TANK OLOSURE 0 TANK REMO1'ED Co:r <br /> DBA OR FACILITY NAME WHERE TANK 15 INSTALLED: 09�1 - <br /> L TANK DESCRIPTION COMPLETE XLL ITEVS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK LD.s 441(( Px�if� �Ll,, 9. Nh?f1FACTUREO BY, Xerxes <br /> C. DATE IN97ALLF0IMOIDAVIYEAR) �'I.k 0.TANK CAPACITY IN CALLON& 115 I Dvo <br /> II.TANK COMM IFA-IISMARKEDCOVPLET9ITEMa <br /> A_ 1 MOTOR VEHICLE FUEL 1 4 OIL B, C- ® la REGULAR8 3 DIESEL C d AI4ATION 13AS <br /> UNLEADED 4 GASAHOR <br /> ❑ 2 PETROLEUM ❑ Ba EMPTY Y PROOUCT O iEPREMIUM E— HANDL <br /> UNLEADEDEl 5 JET FUEL <br /> 2 CHEMICAL PRODUCT 1 ITS UNKNOWN O 2 WASTE Q 2 LEAnEo Pp OTHF-R 0MR199 1% I=M 0. BELOW! <br /> O. IF(A.1)IS NOT MARKED, ENTER NAME OF SLXWAyGE STORED C A 9• <br /> III. TANK CONSTRUCTION MARK 0-4517--V ONLY IN LOXES A.B.AND--AbU ALLTHAT APPLIES IN BOX D AND E--F'�Ve <br /> A. TYPE OF J-H 1 DOMLE WALL 3 WGLE WALL WTTN EXTERIOR LINER 95 UNNNOWN <br /> SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CON70MINT (VAULTEDTANIQ © 99 OTHER <br /> B. TANK Q 1 EARS STEEL ❑ 2 STAINLESS STEEL a mgam um 4 STEEL CLAD W1 FSEROLASS REINI 10ACED PLASTIC <br /> MATESAL ❑ 5 CONCRETE a POLYVINYL,CHLORIDE 7 ALUMINUM �0 IDOSE METHANOL COMPATBLEIVFR? <br /> (RIIIH�T4nII} I BRONZE 10 GALVANIZED STEEL ❑ e5 UNKNOWN © N OTHER <br /> 1 RUBBER LIMED z] z ALKYD LINNO Q 9 OKM LINING © 4 PHENOLIC LIQIND <br /> C.IN © 5 GLASS LINING <br /> LININGINING s UNONED 9S UNKNOWN W OTHER <br /> - - - <br /> O_❑B LINING MATERIAL COLIPATIMAE WITH 100%METHANOL 7 YES X NO— <br /> F-1 <br /> I POLYETHYLENE WRAP ❑ 2 COATING S VINYL WRAP fg a FIIERMA.4S 14 NPUNMD PLASTIC <br /> PROTECTION 0 S CATHODICF-mTECT1PN 01 1GINE N UNKMDWN O N OTHER <br /> E SPILT.AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) ��g r OVERFILL PREVENTION&mIPMENT INSTALLED(YEAR! <br /> 1Y-PIPING INFORMATION CIRCLE A EAVINeGN xWOR U IF 011DEMAOUND,BIOTHIFAPPLIOAII& <br /> A. SYSTEM TYPE A U 1 sUDTION Aipt PRESSURE A U 9 dmAwrf A U 09 OTHER <br /> B. GONSTRUCTIGN A U 1 sHGIl WAIL 2 OOLISLE WALL A U 3 LINED TMMM A V os LS 14NOWN A V 30 OTHER <br /> C. MATERIAL ANC A U I BARE STEEL A I 2 'STAINLESS SSL A U 9 POLYwwL CHLORIDE IPVCf A& 4 FIBERGLASS PIPE <br /> CORROSION A U s ALLIMM i A U s CONCRETE A U' 7 STE@I.VIBOOATING A a)e TIAS METHANOL OOMPATffiLPVwFRP <br /> PROTECTION A U 4 QALVAWSD STEEL A U 10 CATHODIC PROITECTION A U 06 UNKNOWN A U 90 OTHER <br /> D. LEAD DETECTION 1 AUTOMATE LlA;LLL OEIECTOR Q 2 Lala'Fr4n r,SS TWTIN6 19 1 0= <br /> 0 W OTHER <br /> V.TANK LEAK MECTKIN <br /> 1D 1 `VISUAL CHECK ❑ a 7VYEIYI'ORY p�ONC�IATION 8 VAOO2EIAONITDRING 4 ALIT'nMATIGTANKr,.A N4 a GROIII+IDWATERMONnCRHNO <br /> ❑ 8 TANK TESTMIG i 11INTERSTIT1 MOMMING Q 91 NONE of l7vwmN 0 SO OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> i. DATE LAST tlBED(MOIDAYlYFp . L ESTDiAT1,D G(IINrlOY QF L WAS TANK FILLED"ITH ygg ND <br /> MMSTANCERE'IWNING GALLONS 1NERTLATERIAL9 <br /> VWS FOM HAS WXro COMPLETED UNDER PENALTY IF PSiJUR Y 7-0 THE 9ESTPF Oar KNOW EDGE IS TRUE AND CI RC-CT <br /> cA sNAmE .DATE ;� . <br /> ... ... .oaf <br /> S r <br /> LOCAL AGENCY USE ONLY THE STATE LG.NUMSER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> C��OLM--I ty 19 JURISDIGTKW I FAMOY 0 TANK a <br /> LLI <br /> STATE I.D.t 1 7 V15 I I I5] ' <br /> PERMIT NUMBER <br /> PERMIT APPROVED 8YlDATE PERMIT EXPIRATION DATE <br /> THa FORN wisT 6E ACCOMPANIED BY A PERMW APPLICAU*-FORM A,UNLESS A CURRENT FORM A HAS BEM FLED. <br /> FILE THIS FORM WR'HirAL AGENCY IMPLENENfING THE UNDERGROUND STOR E TANK REGULAMNS <br /> FORM 102.91) S (/�� / Fglom�B�I► <br /> LOO/EOOI�j 'TIO TINS OCT9SL90T9 RVct ST:TT�5S6/9T/T4 <br />