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J 1 N 1 C V r 4+NL1 r•V rf IV IN WATER RESOURCES CONTROL BOARD FORM `B': IUNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION IN FORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING FORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO K ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED / FACILITY7SITE NAME WHERE TANK IS INSTALLED: "�' FARM TANK-YES NO ❑ 1 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERETANK 8. MANUFACTURED BY: C. YEAR IND. TANK CAPACITY IN GALLONSII. TANK TS IF(A.I),IS MARKED,COMPLETE ITEM C.IF(A.T),IS NOT MARKED,COMPLETE ITEM D. A I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 60 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER)DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.N C.A.S.q: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.MATERIAL ❑5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER li C. INTERIOR F-1I RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCEDPLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 5 UNKNOWN A U 99 OTHER A U 1 STEDUIRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5ALUMINUM A CONCRETE A U 7STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A ! 5 UNKNOWN A U 99 OTHER ,V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 8 1 VISUAL CHECK PS INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 4. ESTIMATED DATE LAST USED(MOIYR) 2. ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES [-] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED B SIGNATURE) DATE LOCAL AGENCY USE ONLY CONTY q JURISDICTION X AGENCY q FACILITY ID 0 TANK ID O U CURRENT LOCAL AGENCY AGILITY ID F APPROVED BY NAME PHONE F WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK F PERMIT AMOUNT SURCHARGE AMT. FEE CODE pECEIPT F BY: WISCJ FORM B(6-29-68) THIS FORM MUST BE ACCOMP;4mrY A FACILITY7SITE APPLICATION, FORM 'A',UNLESS MURRENT FORMA' MAS BEEN FILED DATA PROCESSING COPY