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esou^ces <br /> STATE OF CALIFORNIA A: ' ` <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> •CSI IROM N'' <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 1Y�rl NEW PERMIT 0 3 RENEWAL PERMIT a 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM El 2 INTERIM PERMIT F1 4 AMENDED PERMIT a 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED O <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: �( G "t�R.vG 1� > lRt7 P <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN l <br /> A OWNER'S TANK I.D.# 3 B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) 5�� / D. TANK CAPACITY IN GALLONS: Z U170 <br /> IL TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. <br /> A. CS,-I-MOTOR VEHICLE FUEL F__j 4 OIL B. C to REGULAR UNLEADED O 3 DIESEL 0 6 AVIATION GAS <br /> 2 PETROLEUM ED BO EMPTY PRODUCT a 1b PREMIUM UNLEADED E] 4 GASAHOL a 7 METHANOL ))) <br /> El 1C MIDGRADE UNLEADED D 5 JET FUEL E] 8 M85 <br /> 3 CHEMICAL PRODUCT 95 UNKNOWN � 2 WASTE E::] 2 LEADED D 99 OTHER(DESCRIBE IN ITEM D.BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D AND E <br /> A. TYPE OF T\I 1 DOUBLE WALL a 3 SINGLE WALL WITH EXTERIOR LINER 1:1 5 INTERNAL BLADDER SYSTEM E] 95 UNKNOWN <br /> SYSTEM F-1 2 SINGLE WALL 0 4 SINGLE WALL IN A VAULT El 99 OTHER <br /> B. TANK F__j 1 BARE STEEL D 2 STAINLESS STEEL 0 3 FIBERGLASS 11. 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL f__j 5 CONCRETE O 6 POLYVINYL CHLORIDE 0 7 ALUMINUM a 8 100% METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) 0 9 BRONZE 0 10 GALVANIZED STEEL [::] 95 UNKNOWN a 99 OTHER <br /> C.INTERIOR 0 i RUBBER LINED FD 2 ALKYD LINING F-1 3 EPDXY LINING a 4 PHENOLIC LINING <br /> LINING OR F_� 5 GLASS LINING UNLINED 095 Uy KNOWN E:] 99 OTHER <br /> COATING IS LINING MATERIAL COMPATIBLE WITH 100°/6 METHANOL? YES /NO_ <br /> D.EXTERIOR 1 POLYETHYLENE WRAP O 2 COATING El 3 VINYL WRAP 24 FIBERGLASS REINFORCED PLASTIC <br /> CORROSION <br /> PROTECTION 5 CATHODIC PROTECTION 91 NONE 1 6792 95 UNKNOWN E:l99 OTHER <br /> E.SPILL AND OVERFILL,etc. SPILL CONTAINMEN ALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> INST <br /> DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A& 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A 2 DOUBLE WALL A U 3 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)Ag)4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC ROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION MECHANICAL LINE LEAK [::]2 LINE TIGHTNESS 3 CONTINUOUS INTERSTMAL 4 ELECTRONIC LINE AUTOMATIC PUMP E] 99 OTHER <br /> DETECTOR TESTING MONITORING LEAK DETECTOR SHUTDOWN <br /> V.TANK LEAK DETECTION <br /> Q 1 VISUAL CHECK � 2 MANUAL INVENTECONCILIATIONORY 3 MONITORING VADOZE [0'4 GAUL NGAUTOMATIC TANK 5 MON TORINGGROUND WATER 6 TESTINGTANK <br /> Fg/'7 CONTINUOUS <br /> MONITORING INTERSTITIAL [:] 8 SIR El 9 WEEK LY MAN <br /> NUAL 0 10 MOTESTINGHLY TANK E] 95 UNKNOWN El 99 OTHER <br /> VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) !� 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> i SUBSTANCE REMAINING GALLONS INERT MATERIAL? <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY O ERJU ,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> TANK OWNER'S NAME .W AS(JJ� - DATE <br /> ,M <br /> (PRINTED 6 SIGNATURE) 1N�/� / yy <br /> -4-4 <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# �� L G -7 <br /> STATE I.D:# mFKFDTI 1%13 111p <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM <br /> SHOULD BE ACCOMPANIED BY A PLOT PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM B (6-95) 1p./0?f1gdo fy <br />