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`rMB.BrVHN FORM `B': Is WATER RESOURCES CONTR(WARD UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION I F COMPLETE A SEPARATE FORM WITH THE FOLLOWIN ORMATION MARK ONLY El NEW PERMIT NR NATION FOR EACN TANK. ONE ITEM ❑3 RENEWAL PERMIT ❑2 INTERIM PERMIT 5 CHANGE OF INFORMATION `o FACILITY/SITE NAME ❑O AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑T PERMANENTLY CLOSED F I. TANK DESCRIPTIONRE TANK ISIP1srALLEo: oZ 3 CIS 7gNK REMOVED COMPLETE ALL ITEMS_IF UNKNOWN— / FARM TANK'YES NO A. OWNERS TANK ID# /C SO SPECIFY ❑ F'► C. YEAR INSTALLED B. MANUFACTURED BY: OD 11. TANK CONTENTS D. TANK CAPggry IN GALLONS: IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. A. ❑1 MOTOR VEHICLE FUEL ❑ ❑3 CHEMICAL PRODUCT 2 PETROLEUM ❑4 OIL B. C. ❑1 UNLEADED ❑2 LEADED ❑5 HAZARDOUS ❑BO EMPTY 95 UNKNOWN ❑ I PRODUCT ❑4 GASAHOL ❑3 DIESEL D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF ❑2 WASTE ❑5 JET FUEL 06 AVIATION GAS HAZARDOUS SUBSTANCE STORED 8 C.A.S.# ❑T METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D C.A.S.#: A.TYPE OF ❑1 DOUBLE WALLED SYSTEM ❑3 SINGLE WALLED WTIH EXTERIOR UNER ❑2 SINGLE WALLED ❑q SECONDARYCONTAINMENT M UNKNOWN ❑ I STEEUIRON ❑99 OTHER MATERIAL ❑ B.TANK 6 CONCRETE ❑2 STAINLESS STEEL ❑3 FIBERGLASS 4 ❑6 POI CHLORIDE ❑ STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC EDElT ALUMINUM ❑ 9BRONZE ❑ 8100%MEfHANOL COMPATIBLE FRP D. INTERIOR 10 GALVANIZED STEEL [_1 ❑2 I R1BBERUNED ❑99 OTHER ALKYD UNING KNOWN ❑3 EPDXY LINING LINING El5 GIA45UNING E]6 UNLINED 1❑I 4 PHENOLIC LINING ❑ISUNING MATERIAL COMPA7BLEMRL 100%METHANOL, `Ll"UNKNOWN E]YES ❑NO ❑99 OTHER D. CORROSION ❑I POLYERILENEWRAP ❑2TAR OR ASPHALT PROTECTION 5 GTHODIC PROTECTION 91 NONE❑ ❑3 VINYL Wggp ❑4 FIBERGLASS REINFORCED PLASTIC ❑ Q j-wONKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE IFA13OVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE B.CONSTRUCTION A U 1 SINGLE WALLED A A U 3 GRAVITY A U 91 NONE U 2 DOUBLE WALLED A 95 UNKNOWN A U 99 OTHER A U 3 UNED TRENCH q U 91 NONE A 5 UNKNOWN p A U 5 ALUMNUM A U 2 STAINLESS STEEL A U 89 OTHER C. MATERIAL A U S ALUA1lAM A 6 CONCRETE U 3 POLYVIT4YL CHLORIDE(PVC) A U O fleERGLASS PIPE A U 9 GALVAMZEDSTEEL A U T STEEL CLAD W/FRP A U 91 NONE 5 UNKNOWN A U 99 OTHER A U B 100%METHANOL COMPATIBLE FRP V_ 1F�A(aE7FL`TJ�JM SYSTBJ/ O'aCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S / VISUAL CHECK P $ 2 INVENTORY RECONCILIA710N P g 3 VADOSE WELLS P S 6 PRECISION TESTING 1 8 1 PRESSURE TESTING 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 95 UNKNOWN P 8 99 OTHER- 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN 3.Wq5 TANK FILLED WITH THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BESTLOF MY KNOWLEDGE,IS TRUE AND)CORRECT ES [ NO LO..- INERT MATERIAL? ( APPLICANT'S NAME PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY �� CJ�/O��U��N(T//�Y�7# �� JURISDICTION —`•fes AGENCY# (' FACILITY ID# TANK ID# CURRENTLOCAL AGANC F CI Ip# LYS ILC APPROVED BY NAME PERMIT NUMBER PHONE#WITH AREA CODE PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT, FEE CODE RECEIPT# BY• 2 FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED MY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORMA' HAS BEEN FILED/ DATA PROCESSING COPY