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PAbBOARD <br /> TANK r c.ALIFNO <br /> FORM `B': WATER RESOURCES C� <br /> LINO GROUND STORAGE TANK PR(rGRAM <br /> TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Y <br /> arloN <br /> MARK ONLY �1 NEW PERMIT a, <br /> ONE ITEM 3 RENEWAL PERMIT _ <br /> 2 INTERIM PERMIT 5 CHANGEOFINFO <br /> 4 AMENDED PERMIT RMATION <br /> ITE <br /> FACILITY/SNAME WHERE TANK IS INSTALLED: ❑8 TEMPORARY TANK CLOSURE �7 PERMANENTLY CL <br /> L TANK DESCRIPTIO /� ❑8 TANK REMOVED NK 1 f <br /> N COMPLETE ALL ITEMS-IF UNKNOWN-SO S,PECIFY I O FARM YANK-YES NO <br /> A OWNERS TANK ID# t Aa <br /> C. YEAR INSTALLED 00 <br /> B. MANUFACTURED BY: R 00 <br /> 11• TANK NTENTS00 <br /> ~ <br /> IF(A7),IS MARKED,COMPLETE ITEM C.IF(A,T)�IS NOT CA III : ^fid <br /> A 1 MOTOR VEHICLE FUEL <br /> 2 PETROLEUM MARKED OMPLETE ITEM D. <br /> 3 CHEMICAL PRODUCT �q OIL B' <br /> EIED <br /> 0 5 HAZARDOUS C. 1 UNLEADED 2 LEADED <br /> D. IF MOTOR VEHIC <br /> 11 80 95 UNKNOWN EMPTY 1 PRO5 JET FUEL DUCT 0 4 GASAHOL ❑8 DIESEL <br /> HAZZARAR ,ENTER NAME OF DOUS SUBLE FUELSTANCE STORED&C.A.S.# ❑2 WASTE T METHANOL ❑I AVIATION GAS <br /> 99 OTHER(DESCRIBE IN TEM D,BELOW) <br /> 111. TANK CONSTRUCTION <br /> MARK ONE ITEM ONLY IN BOX A,S,C A D C'A�S.#: <br /> A TYPE OF y000etEWAUEp <br /> SYSTEM IL--If J=/ 0 3 SINGLE Wg CO WA E%fERIOR LINER <br /> 2 SINGLE WgtfFD 0 4 SECONDARY COMAINMEM ❑95 UNKNOWN <br /> B.TANK 1 STEEL/IRON 11 2 STAINLESSSTEEL ❑N OTHER <br /> MATERIAL ❑5 CONCRETE cl S POLYVINYL CHLORIDE 0 3 FIBERGLASS 0 4 STEEL CLAD W/FIBERGLASR REINFORCED PLASTIC <br /> C. INTERIOR <br /> E19 BRONZE 0 19 GALVANIZED STEEL 0 7 ALUMINUM 0 8 10096MMANOLCOMPATIBtR FAP <br /> I ❑2 ALKY)LINING RUBBER LINED 95 UNKNOWN 99 OTHER <br /> LINING ❑5 GLASSUNING13 6 UNLINED 1:33 EPDXY LINING 0 q ENOUC LINING <br /> 13 IS UNING MATERIAL COMPATIBLE WITH 199E METHANOL, 95 UNKNOWN <br /> 0. CORROSION E]1 PoLYLTHLENE WRAP ED YES Ej NO 99 OTHER <br /> PROTECTION ❑CAP2 TAR OR ASPHALT <br /> 5 IOCIC PROTECTION 0 91 NONE INYL WRAP 4A REINFORCED PLASTIC <br /> %UNKNOWN <br /> IV. PIPING INFORMATION99 OTHER <br /> CIRCLEA IFABOVE GROUND, U IF UNDERGROUND,BOH IF APPLICABLE <br /> A SYSTEM TYPE A U I SUCTION <br /> B, CONSTRUCTION A U 1 SINGLE WALLED A U 2 PRESSURE A U 3 GRAVITY <br /> A U 2 DOUBLE WALLED A U 91 NONE A U 95 UNKNOWN A U 89 OTHER <br /> A U 1 STEEUIRON A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN <br /> C. MATERIAL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PyC) A U <br /> A U S ALUMINUM A U 99 OTHER <br /> A ,IL 6 CONCRETE 4 FIBERGLASS PIPE <br /> A U 9GAL'::V12ED STEEL A U % UNKNOWN A U TSTEEL CLAD W/FRP A U 91 NONE <br /> A U 99 OTHER A U Slpp96 METHANOL COMPATIBLE FRP <br /> VJ LEAK DETECTION SYSTEM CIRCLE FORPRIMARY,ORS FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST Be CIRCLED. <br /> ASS <br /> 1 Vi9_=__- - P S % '..EYTORY RECONCILIATION P S 3 VApOSE <br /> S 6 Frd_ _ -. .] P S 'ESSURETESTI6 P S 91 _ WELLS <br /> P B 4 ELECTRONICMONITOR P S 5 GROUNDWATER MONITORING WELLS <br /> P 8 95 UNKNOWN <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE P S 99 OTHER- <br /> 1. ESTIMATED DATE LAST USED(MOM 2.ESTIMATED I lI I I OP <br /> SUBSTANCE REMAINING IN 3. WAS TA------------- <br /> NK FILLED WITH <br /> OALLONB INERT MATERIAL? <br /> THIS FORM HAS BEEN COMPLETED UI I PENALTY OF PERUDRY,AND TO THE BEST OF ❑YES ❑NO <br /> APPLICANT'S NAME(NMTfD&SIGNA A�IY KNOWLEDGE,IS TRUE AND CORRECT. <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY. <br /> m V O FACILITY IDM <br /> Imo•//`'. /TMA/NK I�DJM <br /> CURRENT LOCAL AGENCY FACIIII IDy ` <br /> W �•� <br /> `L/r r APPROVED BY NAME <br /> PHONE k WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> J Cl PERMIT AMOUNT IHARGE AMT. FEE CODE <br /> RECEIPTN <br /> BY: <br /> FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIEDACILITY/SITE APPLICATION, FORM W,UNLESS A CURRENIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII FORMANAS BEEN FILED <br />