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1� STATE OFCAUFON" •••••; STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B =�� COMPLETE A SEPARATE FORM FOR TANK SYSTEM. `'°•b•-`' MARK ONLY I 1 NEW PERMIT ❑ 3 RMEWAL PERMIT S 04ANCIE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM 2 INTERIM PERMIT ❑ I AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK DBA OR FACILITY NAME WHERE TANK IS INSTALLED: IA 1. TANK DESCRIPTION COMPLETE ALL ITEMS-SPECIFY IF um000vm A. OWNER'S TANK 1.D.s 021 I B. MANUFACTURED BY: C. DATE INSTALLED(MOCAYMEAR) 0. TANK CAPACITY IN GALLONS: L�Ci 11.TANK CONTENTS r-A-iISMARNE].00MPLETEITEMC. A ❑ t MOTOR VEHICLE FIJEI. ❑ s 0118. C. ❑ 1 UNLFI10 R 3 DIESEL ❑ S AVIATION OAS 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT GASAHOL ❑ ,b PREMIUM UNLE O D 5 FUEL 7 METHANOL ❑ 3 CHEMICAL PROpUCT ❑ 96 uwKNovwN ❑ 2 WASTE ❑ 2 LEADED 90 OTHER (DESCRIBE IN ITEM 0.BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.s AI. TANK CONSTRUCTION MARK ONE ITEM ONLY IN Boxes A.&AND C.ANO ALL THAT APPLIES IN SOX D AND E A. TYPE OF +J t DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ ys UNKNOWN SYSTEM I❑ 2 SINGLE WALL ❑ a SECONDARY CONTAINMENT (VAULTED TANIQ ❑ N OTHER B. TANK ___i 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ ♦ STEEL CLAD WA FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ s CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE WIFRP (PrimarYTsldc) ❑ 9 BRONZE ❑ 10 GALVANIZED 3TEE. ❑ 96 UNKNOWN ❑ is OTHER _j 1 RUBBER LINED ❑ 2 ALKYO LINING ❑ 3 EPDXY Lm4G ❑ . PHENOLIC LINING ❑ s GLASS LINING ❑ 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LININ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES— NO_ D.CORROSION `i 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP f❑ a FIBERGLASS REINFORCED "-nc PROTECTION ❑ s CATHODIC PROTECTION r-t; 91 NONE ❑95 UNKNOWN ❑ 0 or LER E.SPILL AND OVERFILL SPILL CONTA044ENT INSTALLED(YEAR) OVERFILL PREVENTION EOUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IFUNDERGROUND.80THIFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U tN OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 96 UNKNOWN A U 99 OTHER C. MATERIAL AND A U t BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL 04LORIDE(PVC)A U a FIBERGLASS PIPE CORROSION A U S WUM A U 6 CONCRETE A U 7 STEEL.W COATING A U 8 100% METHANOL COMPATIBLE WWW PROTECTION A U 9 VANIZE�STEEL A U 10 CATHODIC A U 96 UNKNOWN A U 90 OTHER D. LEAK DETECTION CD4 AUTOMATIC LINE LEAK DETECTOR U4 LINE TKGNT ess TESTING ❑ MOIMf0N18 Cl 98 OTHER V.TANK LEAK DETECTION 1 t VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAOOZE MONITORING ❑ A AUTOMATIC TAB(GAUGING❑ GROWNO WATER MONITORING e TANK TESTING ❑ 7 INTERSTITIALMONITORING ❑ 91 NOW ❑ 95 UNKNOWN 98 OTHER V1.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOlOAY/YR) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAN04G 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 APPLCANTs NAME (PRIUM a SMATUAW DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW URISDICTION>x FACILITY S TANK x STATE L.D.#• COUNTY# Jr__IL_1 I I 10 10 16 t P6RMNT NUMBER i PERAUT APPROVED awoATE PERMIT EXPIRATION DATE FORM B(7.91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION.FORM A,UNLESS A CURRENT FORM A HAS, Fl D.