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;TATE OF CALIFORNIA 'ATERRESOURCES CONTROL BOARc <br /> FORM 'B': UNDERGROUND STORAGE TANK PROGRAM (aTAN�C TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EAC"TANK. <br /> 1 NEW PERMIT ❑J REFEWALPERM(T ®6 CRM 4GE OF INFORMATION [-]7 PERMA)ENTLY.CLOSFD TAW <br /> PARK ONLY ❑ ❑6 TEMPORARY TANK CLOSURE ❑6 TAWREMOVED <br /> ERMIT - <br /> ONE ITEM ❑2 INTERIM PElf AMLYVD®P R <br /> FACILITY/SITEYS MAWHERE TANK If*WALLM � XO- � -7- 0136 FARM TANK.rE6❑ NO <br /> . TANKDESCRIPTION COMPLETEALLITEMS•IFUNKNOWN-SOSK Y <br /> A <br /> 3 e.MANUFACTURED BY: C P < <br /> OVYfAERS TANK E <br /> C,YEIAR INgTAI I mI Q C O.TANK CAPACITY IN GALLONS: j() 00,i <br /> L TANK CONTENTS W(A1) M MARKED.COMPLETE ITEM C M(ATL a NOT MARKED,COMPLETE ITEM D. <br /> B. —co—, MEN" ®2 LEADED ❑J DIESEL <br /> A ®T MOTOR YL PRO RIE( ❑2 PETRIXEIIM 1 PRODUCT ❑A GAS J� ❑S JET FUEL ❑6 AVUTION GAS <br /> ❑J HAZARDOUS <br /> PRODUCT ❑1 OIL <br /> ❑S ilA7AADOlb ❑00 EMPTY ❑45 I1IAKFIDVVN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DE5CPo8E IN ITEM D.BELOW) <br /> D.IF NOT MOTOR VEHICLE FUEL ENTER NAME(1f CAS.[: <br /> HAZARDOUS SUBSTANCE STORED 6 CAS.f <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY I6 SOX A.IS,C,A D <br /> A TYPE OF ®IOxwwAUm ❑]SMGUE WAIEDWITH EXTERIOR LOU ❑15 LWOwM <br /> SYSTEM ❑2 vwwADlD ❑A SHAIDARt'CONTANMENT ❑M OTAIBR <br /> ❑1 SmjSON ❑2 SIAIAESSSTEEL ®J RBEAGM ❑T SnROUDWIFIBERGUAMFIENFORCEDRASTC <br /> L TAW ❑s cONcIf7E ❑6 Fay,,M MOFIDE ❑T PLU" AA ❑6 1076 LEnWAa COMPATBUE RAP <br /> MATERIAL ❑I SFIO42E ❑10 GALVANIZED STEEL ❑95 AMNNN ❑M ODEA <br /> ❑I RRBER LAED ❑2 ARD LINING ❑J EPoAY LINNIG ❑A FRc4xc DANS <br /> C' ❑S LASS UNNNG 6 M[PED ❑25owaM <br /> LPOWGFZ <br /> ❑IS WIC UATERMLOCIAWATIBLE WITH 100%METWO' ❑YES ❑N] ❑69 OTHER <br /> 0.CORROSION ❑1 p%gTIENEwIYP ❑2 TM CA A9WO ❑J VllMWW ®A FSM.ASS IE[FOFM FUSTIC <br /> PROTECTMTN ❑5 CATHJDC NAOTECTION ❑91 HONE ❑95 NA"NOWM ❑19 ORER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE • U t SUCTION A Ill/2 PRE55UTAE A U ]GRAVITY A U 91 NONE A U 95 UM(ItOVlN • U 99 OTHER <br /> B.COkmUCTIN A U t SINGLE WALLED A 1 2 DOUBLE WALED A U ]LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 I071*R• U t STEEL/IfNMA A U 2 STAINLESS STEEL A U ]PaYVINYI CHLOWOE NVCA A Vj FIRERGUSS PIPE A U 9t HA U 5 ALUMININA A U 6 CONCRETEA U ) 6TEEL CLAD W/FAC A V B 10011 METHANOI.COMF'ATIBLE FR <br /> A Y 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTIAER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY•OR S FOR SECONDARY.A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> f Ll t VISUAL CHECK ♦(j$ 2 INVENTORY RECONCIUATKIN ♦ 0 J VADOSE WELLS IF 8 A ELECTRONIC MONITOR f 6 6 GRTOUN WATER MON TOAING WELLS <br /> f F 6 PRECISK)N TESTING ♦ 5 7 PRESSDAE TESTING ♦ 1 91 NONE f • 95 UNKNOWN <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE ] SAS TAN F Eo wall <br /> L ESTIMATED DATE LAST lI5E0IMO(YRI 2 ESTIMATED WANTrtY Of <br /> SUOSTANCE REMAINING IN NEW MATERIAL' ❑YES ❑ NO <br /> CL11E(Nq <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AN T T E T OF MY KNOWLEDGE.IS TRUE AND CORRECT. <br /> DATE <br /> ADPLK.ANi5 NAME(PRINTED A$IGNATVRE) <br /> G.J. MEYER -U.GT.ANALYST i3 9D <br /> LOCAL AGENCY USE ONLY <br /> COUNTY f JURISDICTION f TAGENCY 1 <br /> CILITY ID f TANK ID f <br /> APPROV[D BY NAY[ nwN[F wall""Calx <br /> CURq[ OCAL AO[M Y FACILITY 10, <br /> c <br /> f[gYR/JPgOVAL OATL KRYR[%MRATIOY DATE <br /> ♦[AAYR Yl161 R <br /> E AT. F[[COOS K[CFIR P fY: �/ <br /> CMlCKF fE•Yrt AMOUNT WftcU M <br /> �I <br /> FogMglc.z9ael THIS FORM MUVTSEA000WAlET""FACilTYIfTTEIMIUTKIIl FORM'A'.lRlfYiAglI1RE%T FOSY'A' IW SEEN FlLED <br /> I Cour <br /> 1 DATA PF... ilkG COPY �', I.O.^.AL HOEING'COPT <br />