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STATE OF CALIFORNIA „ °e <br /> STATE WATER RESOURCES CONTROL BOARD J` . <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B W <br /> ys <br /> O YID <br /> c. ro- o <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM "°"��� <br /> MART(ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ON SITE <br /> ONE REM 2 INTERIM PERMIT O 4 AMENDED PERMIT D 6 TEMPORARY TANK CLOSURE 0 8 TANK REMOVED �L <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: -_J S Co ' ,,q-7!5 y ' <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNERS TANK 1.D. 1 _ 3 B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MODAYNY AR) b 4 0. TANK CAPACITY IN GALLONS: u) <br /> ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. <br /> A 1 MOTOR VEHICLE FUEL O 4 OIL B. C. la REGULAR <br /> O 3 DIESEL O B AVMTIONGAS <br /> 2 PETROLEUM 0 80 EMPTY 4-1 PRODUCT ��y_,,(� 1b PREMIUM 4 GASAHOL 7 METHANOL <br /> UNLEADED Q 5 JETFUEL O <br /> O 3 CHEMICAL PRODUCT O 95 UNKNOWN 2 WASTE O 2 LEADED O 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(AI)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,8,AND C,AND ALL THAT APPLIES IN BOX D AND <br /> A. TYPE OF 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTEDTANK) O 99 OTHER <br /> B. TANK F71 BARE STEEL 2 STAINLESS STEEL ❑ 3 FIBERGLASS 54 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL Q 5 CONCRETE F7 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM O 8 100% METHANOL COMPATIBLE W/FRP <br /> (Prlmuy Tank) O 9 BRONZE O 10 GALVANIZED STEEL O 95 UNKNOWN 99 OTHER <br /> O 1 RUBBER LINED O 2 ALKYD LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR 05 GLASS LINING 54 6 UNLINED F--] 95 UNKNOWN O 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— <br /> D.CORROSION O 1 POLYETHYLENE WRAP F-1 2 COATING F-] 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION E:] 91 NONE O 95 UNKNOWN 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) I OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE AIFABOVEGROUNDORUIFUNDERGROUND,BOTH IFAPPLICA13LE <br /> A. SYSTEM TYPE A U 1 SUCTION A(:U)2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A 1 SINGLE WALL A U 2 DOUBLE WALL A LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) FIBERGLASS PIPE <br /> CORROSION A U S ALUMINUM A U a CONCRETE A U 7 STEEL W/COATING A U 6 100% METHANOL COMPATIBLE W/FRP <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 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING INTERSTTLAI <br /> ORING Q 99 OTHER <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK 1—)OOO2 INVENTORY RECONCILIATION 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> 6 TANK TESTING 7 INTERSTITIAL MONITORING 91 NONE O 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAWYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES O NO <br /> SUBSTANCE REMAINING GALLONS I INERT MATERIAL? <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS N \ PATE <br /> IPPINTE98 SIGNA �I,J /- S <br /> LOCAL AGENCY USE ONLY HE STATE I.D.NUMBER IS COMPOSED OF TH9 FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# / <br /> STATE I.D.# /� Lij 1 11 k <br /> PERMIT NUMBER PERMR APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMrr APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> 6090074 <br />