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.a. ••� <br /> STATE OF CAUFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD s�� �m <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> COMPLETE A SEPARATE FORM F(:fVEACH TANK SYSTEM. <br /> MARK ONLY I NEW PERMIT Q 3 RENEWAL PERMIT u 5 CHANGE OF INFORMATION Q T P SED ONSITE <br /> ONE ITEM 2 INTERIM PERMIT Q a AMENDED PERMIT Q 6 TEMPORARY TANK CLOSURE Q 8 LW <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Jo jI7 •1—ond t 17 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEEMS- SPEC:FY IF UNKNOWN % } <br /> A. OWNERS TANK 1.0. I �;Ly - D I I S/MANUFACTURED BY: i 1 CI n-1 zmi r.nnerr <br /> C. DATE INSTALLED(MC/OAWYEARI IAj f:.I !1 Z.{L, `/ D. TANK CAPACITY IN GALLONS ID)000 <br /> ILTANK CONTENTS IFA-1 ISMARKEO.COMPLETEITENI C./ <br /> A i,M 1 MOTOR VEHICLE FUEL Q a OIL S G to REG"UNLEiOb � 3 DIESEL Q 5 AVIATION GAS <br /> Q ® 10 PREMUM UTAEAD© LJ s GASA40L T METHANOL <br /> Q 2 PETROLEUM 80 EMPTY I PRODUCT <br /> to NIOGRACE'UNIADEDL� 5 .IETFUEL B M65 <br /> Q 3 CHEMICAL PRODUCT Q 95 UNKNOWN Q 2 'WASTE Q 2 LEADED EU 99 OTHER(OESCMEH TEM0.BELCYA <br /> 0. F(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C-A S.a' <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.ANO C.AND ALL THAT APPLIES IN BOX D ANO E <br /> A. TYPE OF �� 1 DOUBLE WALL Q 3 SINGLE WALL WITH EXTERIOR UNER 5 INTERNAL BLAMER SYSTEM L 35 UNKNOWN <br /> SYSTEM (✓ 2 SINGLE WALL Q s SINGLE WALL IN A VAULT Q 99 OTHER <br /> 1 use STEL Q 2 STAINLESS STEEL �Q 3 FIBERGLASS Q • STEEL CUD W1 FIBERGLASS REINFCRCEO PLASTIC <br /> B. TANK I T ALUMINUM 8 100X METHANOL COMPATIBLE WIFRP <br /> MATERIAL Q S CONCRETE Q 6 POLWINYL CHLORIDE J L._J <br /> (Primary Tank) Q 9 BRCNZ Q 10 GALVANIZED STEEL 95 UNKNOWN u 99 OTHER <br /> C.INTERIOR IQ i RUBBER LINED Q 2 ALKYO LINING QI 3 EPDXY LINING ❑ A PHENCUC LINING <br /> LINING OR Q 5 GLASS LINING '. 6 UNLINED Q 95 UNKNOWN N OTHER <br /> COATING IS LINING MATERIAL COMPATIBLE WITH 100: METHANOL? YES_ MO— <br /> D.EXTERIOR t POLYETHYLENE WRAP Q 2 COATING jQ 3 VINYL WRAP Q a FIBERGLASS REINFORCED PLAS-..0 <br /> CORROSION I� <br /> PROTECTION Q 5 CATHODIC PROTECTION Q 91 NONE 95 UNKNOWN39 OTHER <br /> E SPILL AND OVERFILL,ate. SPILL CONTAINMENT INSTALLED(YEAR) - OVERFILL PREVENTION ECUIPMENT INSTAR'Fn IYEARI <br /> ORCP TUBE YES '2 NO_ STRIKER PLATE YES�. NO_ OISPENSER CONTAINMENT YES. '� NO <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U iF UNCERGACUND.BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U A FLEXIBLE PIPING A U 99 OTHER <br /> B. CONSTRUCTION A U I SINGLE WALL UBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U I BARE STEEL i A U 2 STAINLESS STEa A U 3 POLYVINYL CHLORIDE(PVCIA U A FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM 9 CONCRETE A U T STEEL W/COATING A U 8 100': METHANOL COMPATIBLE W1 P <br /> PROTECTION A U 9 GALVANI ST-EEL 10 CATHOOICPROTECTION A U 95 UNKNOWN AU99 OTHER FCL (Y}^-Lal <br /> IEauwcu u " 2 t➢,F 3 GMNUO15 NIEPS:RIII A BEeIMnC U,E 5 WiOWTc wv <br /> D. LEAK DETECTION �,]t ;� / TSLw9 MONraRw ❑ IAN[I9T8ctaR 9umovn, Q 99 OTHER <br /> V.TANK LEAK DETECTION I <br /> L 1 VISUAL CHECK Q\Z-_M_AW A'L INVENTORY 3 1ADOZE � A AUTOMATIC TANK Q 5 GROUND 'WATER 6 ANNUAL TANK <br /> RECONCILIATION .MONITORING GAUGING MONITORING <br /> T MON TOROUS INTERSTITIAL Q 8 SIR IQ 9 TANK GAUD NGA 0 Q tMOTESTINGHLY TANK Q 95 UNKNOWN Q 99 OTHER <br /> VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) <br /> 1.ESTIMATED DATE LAST USED(MCADAWYR) 2 ESTIMATED OUANTITY OFI 3.WAS TANK FILLED WITH .ES I NO ri <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? —1 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,ANO TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME eTA�c L:L�n 11 o a,L.S A OATS C. <br /> (PRWfm6SIGNANREI 7 F'I�,L- /� r'�'W('.t -f: 0,,m,dr <br /> \ <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS WMPOSED OF THE FOUR NUMBERS BELOW 1 `'� •I �� <br /> COUNTY C JURISDICTION x FACILITY*Cr-12V 71 TANK 0 Y �H <br /> STATE LDJ 5ML u r 3 r 3 3 o 1-7 ? 11 ? <br /> PERMIT NUMBER PERMIT APPROVED BYIOATE I PERMIT EXPIRATION DATE ,I V I I i <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLE' ")N-FORM A.UNLESS A CURRENT FORM A HAS BEEN FRED. FO`--S MUST BE COMPLETED FOR NST`ALLATIORS THIS FORM <br /> SHOULD BE ACCOMPANIED BY A PLOT i" RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE\/TGROUND STORAGE TANK REGULATIONS <br /> ECRM 3 (8-35) <br />