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`bO�A�k'y <br /> P CO <br /> STATE OF CALIFORNIA <br /> s <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 1 NEW PERMIT [7] 3 RENEWAL PERMIT E 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM 2 INTERIM PERMIT F-1 4 AMENDED PERMIT Q 6 TEMPORARY TANK CLOSURE 8 TANK RE <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ISI' i 1-7 � <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A OWNER'S TANK L 0.M 14117-0 B. MANUFACTURED 8Y: Ull <br /> C. DATE INSTALLED(MOIDAYNEAR) I'l-7 2, D. TANK CAPACITY IN GALLONS: ` 9 <br /> 22 <br /> II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. <br /> 1 MOTOR VEHICLE FUEL 4 OIL B. C. <br /> 1. REGULAR UNLEADED 3 DIESEL O 6 AVIATION GAS <br /> � 1h PREMIUM UNLEADED p 4 GASAHOL � 7 METHANOL <br /> 2 PETROLEUM F-180 EMPTY � 1 PRODUCT to MIDGRADE UNLEACED 5 JET FUEL Q B M65 <br /> 3 CHEMICAL PRODUCT F-� 95 UNKNOWN 2 WASTE 2 LEADED E] 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C-A.S.M: <br /> 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C.AND ALL THAT APPLIES IN BOX D AND E <br /> 1 DOUBLE WALL D 3 SINGLE WALL WITH EXTERIOR LINER D 5 INTERNAL BLADDER SYSTEM [-] 95 UNKNOWN <br /> A. TYPE OF <br /> SYSTEM '� 2 SINGLE WALL 4 SINGLE WALL IN A VAULT L] 99 OTHER <br /> B. TANKI 1 BARE STEEL F-� 2 STAINLESS STEEL E] 3 FIBERGLASS 4 STEEL CLAD Wt FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL Q 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIBLE WIFRP <br /> (Primary Tank) 9 BRONZE = 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED E] 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR <br /> LINING OR = 5 GLASS LINING D 6 UNLINED 95 UNKNOWN 99 OTHER <br /> COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— <br /> D.E7(TERIOR p 1 POLYETHYLENE WRAP F-] 2 COATING F-� 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> CORROSION91 NONE D 95 UNKNOWN 99 OTHER <br /> PROTECTION 5 CATHODIC PROTECTION VV <br /> SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREV ENI ION EQUIPMENT INSTALLED(YEAR) <br /> E.SPILL AND OVERFILL,BtC. DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH 1F APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER <br /> S. 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 ACU)1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE WIFRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION 1 MECHANICAL UNE LEAK 2 UNE nGHTNE55 3 CONT NU9U5 INTERSTITIAL 0 4 ELECTRONIC UNE f—1 5 AL1T06WYC PUMP f�l 99 OTHER <br /> DETECTOR TESTING MONITORING LEAK DETECTOR �J SHUTOQWIV LJ <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK E 2 MANUAL INVENTORY Ej 3 VADOZE 4 AUTOMATIC TANK 5 GROUND WATER a 6 ONITORING TESTINGTANK <br /> RECONCILIATION WEEKLYRING <br /> MANUAL 10 MONTHLY TANK 95GAUGING MUNKNOWN Q 99 OTHER <br /> 7 MONITORING INTERSTITIAL 0 6 SIR ❑ 9 TANK GAUGING TESTING <br /> VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) <br /> 2.ESTIMATE�OUANTIIIY OF 3.WAS TANK FILLED WITH YES 0 NOa <br /> 1.ESTIMATED DATE LAST USED(MOIDAYNR) SU13STRNNING 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'S­NAME 'll altt t3 1 DATE yny <br /> (PRINTED&SIGNATURE) 1 �I Lr •',.Ty{Qj o� � IJW � ( "' <br /> Tl <br /> LOCAL AGENCY USE ONLY THE STATE I.D.N R I COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE LD:# <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> THIS FOAM MUST O ACCOMPANIED N A PERMIT OT N E THISFORMORM WITH THE LOCAL AGENCY MPLEMENTINGRENT FORMA THE GROUND STORAGE TANK RMPLETED FOR IEGULATIONSNS. THIS FORM <br /> SHOULD BE ACCOMPANIED BY A PLOT P� <br /> FORM B (6-95) <br />