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FORM `B': . %ol" LIPURNIAX <br /> WATER RESOURCES CONTRC <br /> TANK TANEWGROUND STORAGE TANK p ' . OARD <br /> COMPLETE A SEPARATE FFORM WITH THE FOLLOWING"FORMATION OR MC <br /> APPLICATION INFORMATION "J` <br /> MARK ONLY <br /> ONE ITEM 0 1 NEW PERMIT , . <br /> ❑3 RENEWAL PERMIT H TANK. <br /> ❑P INTERIM PERMIT �5 CHANGE OF INFORMATION c <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED 4 AMENDED PERMITZ <br /> 6 TEMPORARY TANK CLOSURE (��]PERMANENTLY CLOSED TANK 10 <br /> 1 TANK DESCRIPTION COMPLETE qII ITEMS- L7° TANK REMOVED ©p <br /> A. OWNERS TANK ID p IF UNKNOWN_ V FARM -t <br /> SO SPECIFY TANK-YES❑ NO 6 <br /> C. YEAR INSTALLED � # <br /> 11. TANK CONTENTS " B. MANUFACTURED BY: CN <br /> D. TANK CAPACITY IN GALLONS: �(A <br /> A IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A,YI IS N07 MARKED,COMPLETE ITEM D. <br /> i MOTOR VEHICLE FUEL 1� <br /> 3 CHEMICAL PRODUCT 2 PETROLEUM <br /> 4 OIL B' <br /> 5 HAZARDOUS �I—+�Iy� G ❑ 1 UNLEADED �2 LEADED <br /> 80 EMPTY g5 UNKNOWN E ' PRODUCT Ej 4 GASAHOL ❑3 DIESEL <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF 5 JET FUEL <br /> HAZARDOUS SUBSTANCE STORED 8 C.A.S.E 2 WASTE 7 METHANOL ❑6 AVIATION GAS <br /> -111. TANK CONSTRUCTION OTHER(DESCRIBE IN ITEM D,BELOW) <br /> MARK ONE ITEM ONLY IN BOX A,B,C,8 D n C.A.S.s: <br /> A TYPE OF I DOUBLE WALLED <br /> SYSTEM ❑3 SINGLE WALLED WITH EXTERIOR LINER ��� <br /> 2 SINGLE WALLED 4 SECONDARY CONTAINMENT L7 95 UNKNOWN <br /> 1 STEEL/IRON ❑99 OTHER <br />• B.TANK �2 STAINLESS STEEL �3 FIBERGLASS <br /> MATERIAL 5 CONCRETE 6 POLYVINYL CHLORIDE ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> 70 GALVANIZED STEEL 9 BRONZE ❑ ]ALUMINUM 11 B IGO%METHANOL COMPATIBLE FRP <br /> �95 UNKNOWN <br /> 1 RUBBERUNED ❑99 OTHER <br /> C. INTERIOR �2 AU(YD LINING �3 EPDXY LINING <br /> LINING ❑5 GLASS UNING6 UNLINED d PHENOLIUUNING <br /> F�� <br /> IS LINING MATERIAL COMPATIBLE WITH IBp%METHANOL? E J"UNKNOWN <br /> YES []NO 0 99 OTHER <br /> D. CORROSION I POLYETHLENEWRAP []2 TAR OR ASPHALT <br /> PROTECTION ❑3 VINYL WRAP E1 4 FIBERGLASS REINFORCED PLASTIC <br /> 5 CATHODIC PROTECTION E]91 NONE <br /> E�-95 UNKNOWN 0 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br />' A.SYSTEM TYPE a u 1 sucTloN <br /> A U 2 PRESSURE A U 3 GRAVITY <br /> B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 9 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON U 91 NONE A 9 NKNOWN A U 99 OTHER <br /> C.MATERIAL A U 2 STAINLESS STEEL A 17STE:EL <br /> INYL:GH:L0RIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> A U 5 ALUMINUM A U 6 CO RETE A U CLA <br /> A U 9 GALVANIZED STEEL A Q 9 UNKNOWN A U 8 100%METHANOL COMPATIBLE FRP <br /> A UR <br /> EAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> S 1VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS PS 4ELE IC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P <br /> nS <br /> ' P S 6 PRECISION TESTING P 3 ] PRESSURE TESTING P g 91 NONE <br /> UNKNOWN P 3 99 OTHER <br /> 'FORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> /ESTIMATED DATE LAST USED(MO/YR) 2 ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN I DAL INERT MATERIAL? n YES NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION <br /> � AGENCY p FACILITY IDR TANK ID N <br /> 0 10 1 I � Z S I o 10 <br /> APPROVED By NAME PHONE K WITH AREA CODE <br /> CURRlNT LOCAL AGENCY FACILITY IDI ^5 113-� OJ` PERMIT APPROVAL DATE ,�, ')PERMIT EXPIRATION DATE <br /> PERMIT NUMBER <br /> FEE CODE ^7!1"N <br /> --`URCNARC <br /> CHECK N PERMIT AMOUNT E AMT. <br /> - <br /> YppACILITYISTtEAPPLICATION, ORM-N,UNLESS AC ENT FORMA' NAS BEEN FILED <br /> __. ...,. .MMUSTBEA000MPANIE DATA PROCESSING COPY _ _ _-- <br />