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5�U ES <br /> STATE OF CALIFORNIA <br /> - YIp <br /> • STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B Y� <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PEIIMANENTLY CLOS",N - <br /> 7ONE ITEM 02 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Ccs ( ( () <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# , B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) D. T"NK CAPACITY IN GALLONS: o V <br /> II.TANK CO TENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> A <br /> 1 MOTOR VEHICLE FUEL F--] 4 OIL B. C. 0 1a REGUL R 3 DIESEL 6 AVIATION GAS <br /> 2 PETROLEUM 80 EMPTY R211 �1 PRODUCT 1b PREMIUM 4 GASAHOL 7 METHANOL <br /> UNLEADED F 5 JET FUEL <br /> 3 CHEMICAL PRODUCT O 95 UNKNOWN a 2 WASTE 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> L D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: 0( t lr <br /> (c t <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 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER <br /> 1 BARE STEEL '2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK <br /> MATERIAL 7 5 CONCRETE O 6 POLYVINYL CHLORIDE 7 ALUMINUM 0 8 100% METHANOL COMPATIBLE W/FRP <br /> (Primary Tank) ❑ BRONZE 10 GALVANIZED STEEL E 95 UNKNOWN E 99 OTHER <br /> F7 1 RUBBER LINED El 2 ALKYD LINING F--j 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR a 5 GLASS LININGUNLINED 95 UNKNOWN 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100/ METHANOL? YES_ NO <br /> D.CORROSION F--] 1 POLYETHYLENE WRAP F--] 2 COATING F-1 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION F,—] 5 CATHODIC PROTECTION [�] 91 NONE �5 UNKNOWN 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION Ao 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A(p 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A@ 1 BARE STEEL A @) 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 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 PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> INTERSTITIAL <br /> D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR U-2 LINE TIGHTNESS TESTING ❑ 3 MONITORING ❑ 99 OTHER <br /> V.TANK LEAK DETECTION <br /> VISUAL CHECK 2 INVENTORY REiVvCONCILIATION r 3 VADOZE MONITORING a 4 AUTOMATIC TANK GAUGING 5 GROUNDWATER MONITORING <br /> TANK TESTING 0 7 INTERSTITIAL MONITORING � 91 NONE � 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION t <br /> 1.ESTIMg ATE AS USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITHYESNO <br /> (Q SUBSTANCE REMAINING GALLONS INERT MATERIAL? <br /> r <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND XO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANT'S NAME ( - DATE n <br /> (PRINTED BSIGNATURE) 7, o �..('��. � �.. 7 14/}_ n_ yI illw� 3 f+( <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW Vim/ tttiYY/ f <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.DX <br /> PERMITNUMBER PERMIT APPROVEDBY/DATE PERMIT EXPIRATION DATE <br /> FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT AI*IlCATt04-FORM A,UNLESS•A CURRENT FORMA HAS BEEN FILED. <br /> FOR003411-145 <br /> S <br /> n,•. .j:ST. ...... -•. .�"- _ C ,.� a,d**.,r'.. �.�`Ji:�. 4 k",:*""itR .., ` _-. ...-.:......, „n>&_ IV ,. .........H .u>. <br />