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STATE OF CALIFORNIA <br />STATE WA -TEA RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 7. <br />0 <br />I <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br />1 NEw PERT 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION T PERMANENTLY CLOSFD ON SITE <br />MARK ONLY <br />ONE m2 INTERIM PERMIT + A)J£NDEZ PERMIT Q6 TEMPORARY TANK CLOSURE El e TALAR REMOVED <br />DDA OR FAaLJTY NAME WKERE TANK IS INSTALLED: + <br />I. TANK DESCRIPTION Co+WLETE ALL rTEMa - 8P'ECiFY IF UNKNOWN <br />PCiL OWNER'S TANK I. D. i B, MANUFACTURED BY: <br />. GATE INSTALLED (MO'DA.YP(kM) . i I .r4- 0 le 1I,? D. TANK CAPACITY IN liAll�iW3: a <br />11. TANK CONTENTS Ir A•I IS UARNED. CIOMPLETE ITEJA C. <br />FUEL + OIL & <br />C. 14 REC;u,A)+ CED <br />9 DIESEL 6 AVIATION 618 <br />i MOTOA YE.IICIS <br />1P PREU" UNLE►DED <br />4 GASAfHOL 7 YE HANOL <br />2 PETROLEUM e] EMPTY f PRODUCT <br />tc wDr>IaA!}E UtAE4?ED <br />D JET FUEL Lj E WaS <br />3 CHWICAL f R0XCT a 95 UNKNOWN 2 WASTE <br />2 LEADED <br />Ed <br />99 GTHER CDE$CASE X REW O. B0-0w <br />D. IF (ill) IS NOT MAAKEU ENTMA NJJI6 CF rIUB rTANCE STORED <br />C- A- 8- 0: <br />Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXE5 A E, AND C, AND ALL THAT APPLIES IN DaX 0 AND E <br />I DOUBLE WALL s SINGLE WALL WITH EXTEAJCA UNER 5 INTEAINAL BLADDER SYSTEM a105 UNK140YVN <br />AE OF 99 <br />SYSTEM ❑ Y SINGLE WALL O I SINGLE WALL IN A VAULT OT MER <br />I BARE &TEFL L] a 6T.NLKS5 STEEL F7 7 ABERGLf$S O 4 STE€L CLAD wl rIBERGLASS REINFORCED PLASTIC <br />S. TANK <br />MATERULL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE ❑ 7 ALLUMINU+J a IOOY METHANOL COMPATIBLE W/PRP <br />{Pr6TuryTanN 0 BRONZE 10 GALVANIZED STEEL r7 IM UNKNOvN ❑ 99 OTHER <br />C. INTERIOR C I RUBBER LINED 2 ALKYL? LINING 0 3 EPDXY UNING (-D 4 PHENOLIC LINING <br />LINING OR ❑ 5 GLASS LINING II UNUNEO Q 95 UNKNOWN ❑ a9 OTHER <br />COATING 19 LINING LLATSRLAL COuPATIBL EE WITH i00% METHANCL 7 YES _ NO— <br />D. EXTERIOR C i POLYETHYLENE WRAP [' 2 COA-17NG C a VINYL WRAP ♦ E19ERGLAE.S REINFOACEO PLA91IG <br />CORROSION 91 NONE 99 UNKNOWN El RD OTHER <br />PRoTEcnow Lle CrLTa00rG I'RoTt cnoN [] <br />SPSLL CONTAINMENT STALLED (YEAR)4004 <br />OvERF f REV0h iON EOUI 41ENT INSTALLED (YEAR) <br />E SPILL ALIO OVERFILL, ec. DFIOP TU96 YE9 NO KCfiR PLATE YEg NO D15PE �{ I+O <br />MI <br />IV. PIPING INFORMATION GIRIU <br />CLF A IP ADOve GPONO OR U IF UNOER ACXJNO. BOTH IF APPUCABLE ' <br />A. SYSTEM TYPE A(U), SUCTION A U 2 PR5B5UPE A U 9 GRAVITY A U 4 FLF ISLE PIPING A U vu OTHER <br />8. CONSTRUCTION A U i SINGLE WAIS, A DOUBI.fi WALL A U 3 LINED TRENCH A U 05 UNKNOWN A U 99 OTHER <br />C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC)A U ♦ FIDE14GLASS PIPE <br />CORROS1CNd A U 6 ALUUINUM A U 0 CONCHETE A U 7 STEEL'W COATING A U 0 Io0'4 METH G - ISLE wIFRP <br />PROTECTION A U 9 iiALVANI2FD 6T EEL A U 1C CAT}i001CPROTECTION A U 135 UNINOWN .: A OTHER n,ig7 di JfX_ <br />0. L[AK DETECT}ON I 'Kewrorx uw Lw 2 Ixt Tuxnw a 3 ccwTW s Ui4Pd1SNMl + �& T LIQ e aUtc,uic rut 69 OTHrtA <br />n>rrm Iowtww <br />V. TANK LEAK DETECTION <br />I VISUAL C-ECK 2 IA ONCIUATIDNOqY f7]3 VADOZMcN!ITORINL3 ♦ G L1GINa C TAMC 5 u0mrTORINp�GAOUND R C e TESTSNf3APYNUALTANK <br />7 C:ONTINLJOUB IN7ERSTITIAL 9 wk9 WEEKLY MANUAL E] IC MONTHLY TANK 05 UNKNc7WN Dag OTHER <br />R 3 <br />01 N <br />YI: TANK CLOSURE INFORMATION IPEA+.IANeNT CLoSLIRE INpocc <br />t. GBTLwTbO DATE LAST ABED (Ij[YDAY(YP) 7. uTIIAATIO QUANTITY OF 3. WAS TAMC FILIIiD WITH YES E) NO <br />SUBSTANCE REMAINING GALLONS INERT MATERIAL T <br />THIS FORM HAS SEEN COMPLETED UNDER PENAL TY OF pEAJURY, AND TO THE SES7OFMY KNOwLEDOE, IS TRUE KIND CORRECT <br />TANK Ow+k&A8 NALIE <br />DATE <br />(PAmt9D i AiONATvPA <br />LOCAL. AGENCY USE ONLY THE STATE LD. NUMBER I8 COMPOSED OF TKE FOUR NUMBERS BELOW <br />CauF;rr>r ,Iuflleolc-noNr FAcrLITr. �.,? <br />ANK 0 <br />STATE I.D.4 T I [ � 1 _ <br />PEEWIT NUMBER PFAMI7 AP.PROVLD BYIDATE PERMIT EXPIRATION DATE <br />TM11 FORM YUB78HOU D BEyACCOMPAMEO BY A PLAT LAIC HLE THIS FORM UNLESS EP4 <br />YrM THL LOCAL AgAWY 1liFILEMOMMOTHE UIIDERCAi UNO BTORkUK TANX RE-OULA'TK*m $ THIS PDF01 <br />Fogg B (5-95) - - <br />eo,d SLIT „LaU_aa-( 'S �Z)LLJ.JLa�{ Cr9�=80 166-91-6rtiy <br />