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• <br />STATE OF CAUFORNIA <br />STATE WATER RESOURCES CONTROL BOARD .`^'� -, e <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B ;e ,�, : ° <br />1n:. <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br />MARK ONLY ❑ I NEW PERMIT I❑ <br />3 RENEWAL PERMIT <br />❑ 5 CHANGE OF INFORMATION <br />❑ <br />7 PERMAA EMILY CLOSEp TE <br />ONE ITEM ❑ 2 INTERIM PERMIT <br />❑ <br />4 AMENDED PERMIT <br />8 TEMPORARY TANK CLOSURE <br />7r3' <br />8 T <br />%EMOVEp <br />DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br />i/ Gr 4- 141 1 <br />I ? <br />❑ 5 POLYVINYL CHLORIDE <br />Vv <br />❑ 8 IOOY- METHANOL COMPATIBLEW/FRP <br />I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br />A OWNER'S TANK L 0. a i 4.117 01 <br />I S. MANUFACTURED BV: i i r. krLxjr. <br />C DATE INSTALLED (MOMAY/YEAR) Ia 77 I 0. TANK CAPACITY IN GALLONS: 1 V 000 <br />N TAkiv /MMTCMTC .e.,. m.aovcn I.R. F - TPU O. <br />A ® 1 MOTOR VEHICLE FUEL❑ 4 OIL <br />❑ 2 PETROLEUM BO EMPTY <br />C::Ic <br />I E. <br />,� t PRODUCT <br />C. to REGULNi UNLiAO® <br />1b PREN2IN UNLEADED <br />MKK.R/OE UNLEADED <br />❑ 5 BiTEANAI BLADDER SYSTEM ❑ 95 UNKNOWN <br />3 DIESEL Ll6 AVIATION GAS <br />A GASAHOL ❑ 7 METHANOL <br />5 JET FUEL El M85 <br />❑ 3 CHEMICAL PRODUCT F-195 UNKNOWN <br />❑ 2 WASTE <br />❑ 2 LEADED <br />B. <br />99 OTHER IDESCAIBE IN REN O. SELOM <br />0. IF (A.1) IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C. A S. " <br />III TAN(( CT)NSTRIICTION MARK ONF REM ONLY IN BOXES A.B. AND C. AND ALL THAT APPLIES IN BOX D AND <br />N/ DiolAln AIC7ICAAATIYTN o,c a mARnvPnRTNR1nnR U IFUNOERGROUND. BOTH IFAPPUCABLE <br />A. <br />❑ I DOUBLE WALL <br />❑ 3 SINGLE WALL WITH EXTERIOR UNER <br />❑ 5 BiTEANAI BLADDER SYSTEM ❑ 95 UNKNOWN <br />A. TYPE OF <br />SYSTEM <br />2 SINGLE WALL <br />❑ A SINGLE 'WALL IN A VAULT <br />❑ 99 OTHER <br />B. <br />T� <br />l5d I BARE STEEL <br />❑ 2 STAINLESS STEEL <br />❑ 3 FIBERGLASS <br />❑ 4 STcE CLAD W/ FIBERGLASS REINFORCED PLASTIC <br />B. TANK <br />MATERIAL <br />❑ 5 CONCRETE <br />❑ 5 POLYVINYL CHLORIDE <br />❑ 7 ALUMINUM <br />❑ 8 IOOY- METHANOL COMPATIBLEW/FRP <br />(Primary Tank) <br />❑ 9 BRONZE <br />❑ 10 GALVANIZED STEEL <br />❑ 95 UNKNOWN <br />❑ 99 OTHER <br />PROTECTION <br />❑ 1 RUBBER LINED <br />❑ 2 ALKYD LINING <br />❑ 3 EPDXY UNING <br />❑ 4 PHENOLIC LINING <br />C. INTERIOR <br />LINING OR <br />❑ 5 GLASS UNING <br />❑ 8 UNLINED <br />95 UNKNOWN <br />❑ 99 OTHER <br />COATING <br />IS UNING MATERML COMPATIBLE %ITN T00% METHANOL? <br />YES _ NO— <br />D. EXTERIOR <br />❑ 1 POLYETHYLENE WRAP <br />❑ 2 COATING <br />❑ 3 VINYL WRAP <br />❑ 4 FIBERGLASS REINFORCED PLASTIC <br />CORROSION❑ <br />❑ CATHODIC PROTECTION <br />ix 91 NONE <br />95 UNKNOWN <br />❑ 99 OTHER <br />PROTECTION <br />5 <br />SPILL CONTAINMENT INSTALLED (YEAH) <br />OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) <br />E SPILL AND OVERFILL-. etc. DROP TUBE YES _ <br />NO _ STRIKER PLATE YES _ NO <br />_ DISPENSER CONTAINMENT YES _ NO <br />N/ DiolAln AIC7ICAAATIYTN o,c a mARnvPnRTNR1nnR U IFUNOERGROUND. BOTH IFAPPUCABLE <br />A. <br />SYSTEM TYPE <br />A U <br />1 SUCTION <br />Ao <br />2 PRESSURE A U <br />3 GRAVITY A U <br />4 FLEXISLE PIPING A U 99 OTHER <br />B. <br />CONSTRUCTION <br />AU <br />1 SINGLE WALL <br />A U <br />2 DOUBLE WALL A U <br />3 LINED TRENCH A U <br />95 UNKNOWN A U 99 OTHER <br />C. <br />MATERIAL AND <br />CORROSION <br />Ao T BARE STEEL <br />A U 5 ALUMINUM <br />A U <br />A U <br />2 STAINLESS STEEL A U <br />6 CONCRETE A U <br />3 POLYVINYL CHLORIDE (PVC)A U 4 FIBERGLASS PIPE <br />7 STEEL W/COATING A U 3 100% METHANOL COMPATIBLEWFRP <br />PROTECTION <br />A U <br />9 GALVANIZED STEEL <br />A U <br />10 CATHCOICPROTECTION <br />A U 95 UNKNOWN <br />A U 99 OTHER <br />D. <br />LEAK DETECTION <br />1 V�uNGI VINE IFAK <br />2 h Td1NE55ncKTx6ss ❑ 3 IKraamu r'j 4 Dtcla <br />5 PuuP E] 99 OTHER <br />U TAM(! I FAIL TTFTFT:TITTN <br />• • •1` VISUAL CHECK _ <br />❑ <br />2 AUTOMATIC TANK ❑ 5 GROUND WATER MONITORING <br />❑ 3 VADOMCNI 'T 4 <br />❑ 6 TESTING <br />n 7 CONTINUOUS INTERSTITIAL <br />❑ <br />RECONGILIATIO�RY <br />ORING GAUGING <br />LY MANUUAL ❑ 10 TANK ❑ gg UNKNOWN <br />❑ 9 WE <br />❑ 99 OTHER <br />MONITORING <br />9 yryq K - TESTING <br />VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) <br />1. ESTIMATED DATE LAST USED (MO/OAWYR) 2. ESTIMATED QUANTITY OFmay' I 3. WAS TANK FILLED WITH YES ❑ NO <br />SUBSTANCE REMAINING <br />-1 <br />SUBSTANCE GALLONS INERT MATERIAL( <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />TANK OWNER'S NAME Zaj1"�(I-1;1.l,rloo y f DATE <br />(PRINTED 491GNATUBE-Y <br />�7 <br />� '17 <br />LOCAL AGENCY USE ONLY THE STATE I.D. NUMBERIS CdiWOSED Of THE FOUR NUMBERS BELOW <br />COUNTY k JURISDICTION M FACILITY x // vul�-TANK N U <br />STATE I.D.4 m F —IT7 �1 rl I 17 1-S Vh Ii I / <br />PERMIT NUMBER I PERMIT APPROVED BWDATE 1 PERMIT EXPIRATION DATE <br />THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPU' -FORM A. UNLESS A CURRENT FORMA HAS BEEN FIL90. FC IST BE COMPLETED FOR INSTALLATIONS. THIS FORM <br />FORM 8 (6-95) P O <br />SHOULD BE ACCOMPANIED BY A PLOT LE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THEI qw <br />OUND STORAGE TANK REGULATIONS <br />