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clA, <br />..A�.S <br />STA7EOFCAUFORMA 41 L/ � .`S ...... <br />STATE WATER RESOURCES CONTROL BOARD i "o <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br />r1 <br />COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br />MARK ONLY 1 NEW PERMIT <br />3 RENEWAL PERMIT <br />5 CHANGE OF INFORMATION 7 PERMANENTLY CLO,§;:n <br />nm cIT[ <br />ONE ITEM 2 INTERIM PERMIT <br />4 AMENDED PERMIT <br />6 TEMPORARY TANK CLOSURE a 8 TANK REMOVED <br />PRODUCT <br />DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br />/ f S/ <br />I,% /— o1./ I `sc- <br />C 95 UNKNOWN <br />I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br />A. OWNER'S TANK I. D. # 3 B. MANUFACTURED BY: �orA/�nS <br />C. DATE INSTALLED (MO/DAY/YEAR) /LD. TANK CAPACITY IN GALLONS: 1D©� <br />L / / <br />11 TANK f1)NTFNTS ICA., ICMA;;KCn cOMPLFTEITEMC_ <br />A 2!1-1 MOTOR VEHICLE FUEL <br />� d OIL <br />B. <br />C. 1a REGULAR LEADED <br />3 DIESEL 6 AVIATION GAS <br />4 GASAHOL <br />2 PETROLEUM <br />❑ 80 EMPTY <br />PRODUCT <br />lb PREMIUM <br />UNLEADED <br />a 7 METHANOL <br />5 JET FUEL <br />3 CHEMICAL PRODUCT <br />C 95 UNKNOWN <br />1� 2 WASTE <br />2 LEADED <br />99 OTHER (DESCRIBE IN ITEM 0. BELOW) <br />D. IF (A.1) IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED <br />7 ALUMINUM <br />8 ICOy METHANOL COMPATIBLE W/FAP <br />C. A. S. #: <br />111 TANK rONSTRACTION MARK ONFITEM ONLY INBOXESA.B. AND C.AND ALL THAT APPLES INBOX DAND E <br />A. TYPE OF <br />1 DOUBLE WALL <br />3 SINGLE WALL WITH EXTERIOR LINER <br />95 UNKNOWN <br />SYSTEM <br />❑ 2 SINGLE WALL <br />d SECONDARY CONTAINMENT (VAULTED TANK) <br />99 OTHER <br />3 GRAVITY A U 99 OTHER <br />LJ 1 BARE STEEL <br />2 STAINLESS STEEL <br />F--,-.r-FIBERGLASS <br />4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC <br />B. TANK <br />MATERIAL <br />5 CONCRETE <br />6 POLYVINYL CHLORIDE <br />7 ALUMINUM <br />8 ICOy METHANOL COMPATIBLE W/FAP <br />(Primary Tank) <br />9 BRONZE <br />10 GALVANIZED STEEL <br />95 UNKNOWN <br />99 OTHER <br />5 ALUMINUM <br />j� i RUBBER LINED <br />G1 2 ALKYD LINING <br />n 3 EPDXY LINING <br />4 PHENOLIC LINING <br />C. INTERIOR <br />— 8 GLASS LINING <br />� 6 UNLINED <br />95 UNKNOWN <br />� 99 OTHER <br />LINING <br />—J <br />LINE LEAK DETECTOR 2 UNE TIGHTNESS TESTINGMoNITCRING OTHER <br />ISLININGMATERIAL COMPATIBLE WITH 100% METHANOL? <br />YES_ NO <br />D. CORROSION <br />1 POLYETHYLENE WRAP <br />2 COATING <br />3 VINYL WRAP <br />� FIBERGLASS REINFORCED PLASTIC <br />PROTECTION <br />5 CATHODIC PROTECTION <br />91 NONE <br />95 UNKNOWN <br />= 99 OTHER <br />E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) <br />OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) <br />IV. PIPING INFORMATION <br />CIRCLE A IFABOVEG <br />NDOR U IFUNOERGROUND.BOTHIFAPPLICABLE <br />A. SYSTEM TYPE <br />A U <br />1 SUCTION <br />A <br />2 PRESSURE A U <br />3 GRAVITY A U 99 OTHER <br />B. CONSTRUCTION <br />A U <br />1 SINGLE WALL <br />A <br />2 DOUBLE WALL A U <br />3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br />C. MATERIAL AND <br />A U <br />I BARE STEEL <br />A U <br />2 STAINLESS STEEL A U <br />3 POLYVINYL CHLORIDE (PVC) A '74 FIBERGLASS PIPE <br />CORROSION <br />A U <br />5 ALUMINUM <br />A U <br />6 CONCRETE A U <br />7 STEEL W/ COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br />PROTECTION <br />A U <br />9 GALVANIZED STEEL <br />A U <br />10 CATHODIC PROTECTION <br />A U 95 UNKNOWN A U 99 OTHER <br />D. LEAK DETECTIONAUTOMATIC <br />LINE LEAK DETECTOR 2 UNE TIGHTNESS TESTINGMoNITCRING OTHER <br />TANK LtAF, Ut 1 tG I [UN <br />1 VISUAL CHECKORY RECONCILIATION 3 VADOZE MONI70RING u d AUTOMATIC TANK GAUG;NGF75 GROUND WATER MONITORING <br />J 6 TANK TESTING 7 INTERSTITIALMONITORING 91 NONE 95 UNKNOWN 99 OTHER <br />VI. TANK CLOSURE INFORMATION <br />1. ESTIMATED DATE LAST USED (MO/DAY/YR)2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES = NO <br />I 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 NAME DATE <br />(PRINTED 6 SIGNATURE) <br />LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br />COUNTY # JURISDICTION X FACILITY # &4 TANK # 17 r-!QA,-1VP <br />STATE LD.�1 p <br />'ERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br />t I �� <br />FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. // f I I �l I' l lI/ <br />L f 01100148 -RS <br />(,UA <br />