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STA OF CALIFORNIA • WATER RESOURCES CONTROL BO <br /> FORM B': UNDERGROUND STORAGE TANK PROGRA <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> I NEW POW ❑S RENEWALPOWIT ®5 GRANGE OF INFONAAT*N ❑7 PEIYMNENTLY.CLOSED TANK <br /> MARK ONLY ❑ A PPERMIT ❑6 TEMPORAW TALK CU09JRE ❑S TANK REMOVED <br /> ONE ITEM ❑2 KINTERIM POW ❑K <br /> _O3 fAIW TANK-YES❑ NO <br /> FACKJTYAtITE NAPE WHERE TANK It iNSTALlEO: <br /> L TANKDESCRIPTION corn.ETEAurtEMS-FLINKN°'A'N-90SPECIfT <br /> A.OWNERS TANK 19 E S.MANUFACTURED BY: (J ' ..{NS ci,- < P <br /> CL BAR INSTALLED 1586, <br /> fi , D.TANK CAPACITY IN GALLONS: Q <br /> II. TANK CONTENTS w(A..),H umwzo,COMPLETE ITEm c'w(A1),M NorA='cOMpLmrrEMD <br /> BIEE.EAOED ❑2 LEADED ❑A DIESEL <br /> A ®1 MOTOR VEWLE RIFT ❑2 PETROLEUM ' <br /> C]I CHEMICAL PRODUCT ❑K OIL ®1 PROWU ❑E(SASNIOL ❑S ET RJEL E]e AVIATION GAS <br /> ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOAN ❑2 WASTE ❑7 METHAL ❑99 OTHER PESpYBE N ITEM D,BELOW) <br /> D. F NOT MOTOR VEHICLE FUEL ENTER NAME OF CAS.E: <br /> HAZARDOUS SUBSTANCE STORED&CAS.E <br /> III. TANK CONSTRUCTION MARKONEITENIONLYNIDOKA,t,C,to <br /> TYK OF 100161ERAUID ❑I SOWIIIIAUIDATTHMUKORUNER 0150000 <br /> A ® <br /> SYSTEM ❑2 vw WALIHI ❑J SKOIUARI cowm&w ❑a one <br /> ❑I STEAL" ❑2 SDIAESSSM ®S RBBIGIASS ❑A MMGAOW/FIBEIY A%K``"OA=KMC <br /> a TANK ❑S 07NC" ❑e POIYMj CHLOROE ❑7 At1AANA( ❑e 10A WDONGLOMPATI&ERP <br /> NATERML ❑19ROIIZE ❑10 GALVAN12®SIEEL ❑95 IPKDOAN ❑99 OTWR <br /> ❑I ALSO VIED ❑2 ALAYMLOONG ❑9 @OAYUTANG ❑J MIENOUCUKNG <br /> C' 6 lF INTERIOR <br /> ❑5 GLASS IWLP" ® um F11 <br /> 95 L"NV <br /> I <br /> ❑ISLNNGMATERALOOWATaEWR tMMETANyL? ❑YTS ❑NO ❑N ORER <br /> 0.CORROSION ❑1 mxmKEMEWMP ❑2 TARORA7%ALT ❑S WK WRAP ®1 FIBERGIASSWMOR=MASTC <br /> PROTECTION ❑5 CATHGOCPROTECTON ❑91 NONE ❑25 LIEDAMVN ❑N OR61 <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND.U F UNOERGROUNO.SOTH IFAPPLICAtLE <br /> A SYSTEM TYPE A U I SUCTION A 2 PRESSURE A U J GRAVITY A U 91 NONE A U 95 UNKNOWN AN 99 OTHER <br /> IL COMMUCTION A U 19MGlE WALLED A U 2 DOUBLE WALLED A U S U+EDTRENCH A U NE 91 NOA Y 95 UNKNOWN A U 99 OTHER <br /> A U ISTEEL/IRON A U 2 STAINLESS STEEL A U S POLYVSIYL CHLORIDE 0%,C) A44FWAGLASS PIPE A U 91 NONE <br /> C.MATERNAL A U 5 ALUMINUM A U 6 CONCRETE A U 2 STEELOUC W/FSR A U 6 I6 METHANOL COMPATIBIF FRP <br /> A U 9 GALVANIZED STEEL A U 95 IMKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY•OR S FOR SECONDARY.A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> ♦C t VISUAL CHECK F 1&2 KLYENTORY RECONCILIATION F t S VADOSE WELLS Q 9 A ELECTRONIC MONITOR F 6 5 GROUND WATER MONITORING WELLS <br /> F ■ 6 PRECISION TESTING F S 7 PRESSURE TESTING F 9 91 NONE F 9 96 UM(NOWN - F 9 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE J WA$TANK FK EU WITH <br /> 1.ESTIMATEDDATE IASTUSEDIMONA) 2 ESTIMATEDOUANTITYOF <br /> SUBSTANCE REMAINING IN Om INERT MATERIAL' E]YES ❑ NO <br /> OALL <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.A O H ST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> DATE <br /> APPLICANTS NAME(PRINTED A SIGNATURE) <br /> G.. . MEYER-U.G.T.ANALYST <br /> LOCAL AGENCY USE ONLY <br /> COUNTY 9 JURISDICTION• AGE <br /> ACILITY 10 E TANK ID E <br /> APPnovEo 9v NAre� / / IHaNc F WITH""CODE <br /> CURRENT ALAGENCYFAA/CILIT' <br /> l� <br /> rtRYR APPIIOVAL DATE rtRYR EXMMTION DATE <br /> F[AYR MU1A <br /> ELKCHARGE AMT. PEE COOS AECEIPTF AY: <br /> CHECK• rtRYR AMOUNT <br /> TORMB(6�Nw) THIS FORK MUST BE ACCOIM ACEITT'/ifiE APPLICAli01L FORM'A',tRaEa ACIIRKKT fOSY'A' (MS LEEN FRED V <br /> 1 DATA SING COPY 2 Loc•w AGENCY COPT "t COPY // <br />