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A, STATEOFCAUFORMA fir. STATE WATER RESOURCES CONTROL BOARD Wyo� ly =� UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B b.an. e COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY 1 NEW PERMIT ❑ 7 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATKIN ` nRMANEN^ ONE ITEM 2 INTERIM PERMIT ❑ A AMENDED PERMIT C 8 TEMPORARY TANK CLOSURE 9 TAN DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN 0. OWNERS TANK 1.0.:1 C ( I E. MANUFACTURED BY: (, C. DATE INSTALLED(MO/DAYNEAR) V-cr 0. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA4 LSMARKED.COMPLETEITEMC. A. f MOTOR VEHICLE FUEL ❑ 4 OK. B. / G ❑ 1aUNLLEUADDED ,'�, < DIESEL 8 AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY I^,I.ff 1 PRODUCT ❑ III PREMIUM U GASAH LpI `' T N��L _ ❑ JET S CHEMICAL PRODUCT ❑ 95 UNKNOWN GI 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM 0. SELOW1 0. IF(A1)IS NOT MARKED. ENTER INANE OF SUBSTANCE STOPED A Lv C.A.S.•: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C.AND ALL THAT APPLES IN BOX D AND A. TYPE OF ❑ 1 DOUBLE WALL I❑ 7 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑— 2 SINGLE WALL ❑ A SECONDARY CONTAINMENT (VAULTED TANK) ❑ 90 OTHER B. TANK L 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ S FIBERGLASS ❑ A STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERNAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFW (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LVED ❑ 2 ALKYD LINING ❑ 7 EPDXY LINING ❑ s PHENOLS LINING C.INTERIOR 5 GLASS LINING LINING ❑ I❑ 8 UNLINED ❑ % UNKNOWN �❑ 99 OTHER L9 LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 0 VINYL WRAP ❑i A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODICPROTECTION ❑ 91 NONE ❑95 UNKNOWN 99 OTHER E SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED IYEARI OVERFILL PREVENTION ECUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.SOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 9 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A V 0 LINED TRENCH A U 95 UNKNOWN A U w OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 9 POLYVINYL CHLORIDE(PVM A U A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELWYCOAnNG A U 8 100% METHANOL COMPAT78LEW/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 90 OTHER 0. LEAK DETECTION [-] 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 UI$TrHTNESSTESTING ❑ T AgNOORING E] 90 OTHER V.TANK LEAK DETECTION U 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ S VA002E MONITORN6 ❑ A AUTOMATIO TANK GAUGING ❑ S GROUNDWATER MONITORING ❑ e TANK TESTING ❑ 7 INTERSTITIALMONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 90 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED D ST U (MOIDAYNR) 2 ESTIMATED QUANTITY OF I 3 WAS TANK FILLED WITH YES SUBSTANCE REMAINING GALLONS WERTMATERWL7 LJ NO THIS FOR HAS B EN COMPUftD UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT APPLICANTS NAME CATE tPMINTFoa 51GNAtullp J IxJ r VI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW C o u-- COUNTY x JURISDICTION is FACRTTY a TANK a I STATE LD.* �i 73 Q PERMITNUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM 8 (12.91) i2 _ _ R Ixtum