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- - — .... �•••••� WA I tH RESOURCES CONTROL BOARD <br /> FORM 'B': UNDERGROUND STORAGE TANK PROGRAM <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK <br /> MARK ONLY ElMANENTLYCL <br /> I NEW PERMIT ❑]RENEWAL PERMIT ❑5 CHANGE OF MWORMT]ON ❑ 7 PERO TANK <br /> ONE ITEM d) ❑2 INTERIM PERMIT ❑A AMENDED PERMIT ❑6 TEMPORARY TAM(CLOSURE 6 TANK REMOVED <br /> FACILFTY/81TE NAME WHERE TANK IS INSTALLED,. ❑ �- <br /> ARM TANK-YES❑ NO G <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 10 <br /> A. OWNERS TANK IO 9 B. MANUFACTURED BY <br /> C. YEAR INSTALLED D TANK CAPACITY IN GALLONS. F-A' <br /> II. TANK CONTENTS IF(A/) IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. 00 <br /> A. ❑ 1 MOTOR VEHICLE FUEL ❑i PE7NOLEUM B /O C ❑ 1 UNI EADED ❑2 LEADED ❑] DIESEL N <br /> ❑ ]CHEMICAL PRODUCT ❑ A Dl ❑ 1 PRODUCT // ❑A GASAHN ❑ 5 JET FUEL ❑6 AVIATION GAS <br /> ❑5 HAIAIK(XU$ ❑60 EMPTY ❑%UNKNOWN ❑2 WASTE ❑ I METHANOL ❑ 99 OTHER(DESCRIBE N ITEM D.BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED 6 CAS.9. * 17 CA.$.F: �3 <br /> -Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.S.C.A D <br /> ' rTYK STEM � Ej I DOLBLE IMUED ❑3WWWALLMMTNDT"L9NL ❑2S Lw)1�❑2 PW WAUM ❑E gW IOAR(WIT WIT ❑ROTHR1 STEHARON ❑i STA9AE4 SIEH ❑]11BERGlASS I STE IOADWAIDER LASSREIMORC$PUSTIC <br /> !S 5 wNCRLTE ❑I PaTY9nL C1LLYIOE ❑ T HI14pAM 9I00%IE71P11IX CO1pATgE FRP❑9 BRONZE ❑N GALVANIEDum ❑9S IHOgWN ❑99 OTHEB <br /> � IIlTF.R10R ❑ 11LBB01IllEil) ❑i NAYOI/NC ❑]EFWLW G ❑•REI"c LWWG <br /> 1:19S UIDKI61 <br /> UMI /6 ❑15 UPGIATBNL C0IPA OMIN KIN,{RWKI YES ❑NO ❑90 Ono <br /> D. CORROSIO&C <br /> 1 POLTETNBEMW ❑2TAR ORASPHALT ❑]"M Mw ❑A RBfRG.ASS KNIOCB)RAM <br /> PROTECTION ❑S CATHM CPROTECDON ❑R NOK ❑ 95 U*UCWW ❑99 DIT91 <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF L4#rf OROLUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A V I SICTKIH A U 2 PRESSURE A U ]GRAVITY A U MOTHER <br /> S. A U 1 SMNOLE WALLED A U 2 DOUOLE WALD:1) A U ] UNED TRENCH A U %UNKNOWN A U N OTHER <br /> C MATERIAL ® A U 1 MatIRON A U 2 STAINLESS STEEL A U ]POLVVWrL CHLORIDE IPYI7 A U A DBUASS KLPIPE <br /> A U 6 ALUMINUM A U 9 CONCRETE A U 7 STEEL Cb WIRY A U 9 10011 METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZEDSTER A U %UNOKWH A U N OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY OR S FOR SECONDARY.A PRIMARY LEM DETECTION SYSTEM MUST BE CIRCLED. <br /> N 7 1 1 VISUAL CHECK P 9 2 INVENTORY RECONCLLATKN P 93VADOSE WUyS P S A E1ECn"mC MONITOR P S 5 OIKIIK WATER MONITORING WELLS <br /> Lam}--r/1 6 PRECISON TESTINI P 6 7 PRESSURE TESTIK P • 91 NONE P • %UNKNOWN P 6 9G OTHER <br /> i VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> �I IMATED DATE LAST USED IMO/YR) STKMATED OUANTm OF <br /> j.( ANCE REMAWIND IN As TANK(REED WITH <br /> MALlOH9 � AIATERIAL7 ❑YES E)NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINT®6 SONATURo W TE <br /> LOCAL AGENCY USE ONLY r <br /> S T S AGENCY I 2 FACILITY 10 S Z TANK l0 6 <br /> a <br /> LQQALABDNX F/KRRYC. <br /> p M PIONS6 WITH ARIA CODE <br /> FSAINi MU1MSR_ . . .� / I/ < <br /> .• • ALDA 9016fTCVIKATIOMBAIS <br /> __ 30 <br />