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Z ' STATEQFCAL]FOR!•dA � <br /> -TAT-'NATER RESOURCES CCNTAQL BOARD <br /> UNDER GROUNtr STORAGE TANK PERMIT APPLICATION"✓FORM B <br /> COMPLETE A SEPARATE FORM FOR-EACH TANK SYSTEX <br /> MARK ONLY ❑ 1 NEW PSrAMrra 3 RENEWAL P$RMtr <br /> �Q <br /> ONE ITEM f7INTE <br /> 2 Ru4 P£amrr < AMENDEO PERMrr a CHANGE CF TANK Wj:OAcTICN j"PERMANENTL CxOSe6 SITe❑ a TEMPORARY TANK GLosunRE Co 8 TANK AEMC p <br /> DHA OR FACILffY NAME'NHERF TANK-IS INSTALLED: <br /> L TANK 0 ESCRIPTION cdMPLETE ALL rrGAS,SP!ECFY tF UNKNOWN <br /> A. OWNERS TANK L 0.s I I B. MArNUFACTUREO 9Y: 1 <br /> C DATE INSTAlLEO(MClpAY/YEAR) O. TANK CAPACITY W GALL941: <br /> II.TANK CQNTENTS rF t t muAAKeo.cOMPLETErrEMC. / 1 <br /> A. ffl MOTOR VENICLE FLtEL ❑ a OIL g� <br /> G ❑ !a REGi1r_AR OICSEL <br /> ❑ <br /> Q 2 PETROLEUM ❑ 80 EMPTY 1 PROOUCT DPREMRJM A OAS, L a AVIATIGV GAS <br /> UNLEACEO S ❑ 7 METHANOL <br /> C:] ] CNESAICALPRCCUCT ❑ 95 UM4VOWN C3 2 WASTE ❑ 2 LEAOEO 90 OTs1Ea tflEScaTeE w ITEM 0. BEIOv>1 <br /> O. IF(A-t)L4 NOT MAAKeO.ENTER NAM£ OF SUBSTANCE SrOaED <br /> C.A.S.4: <br /> III. TANK CONSTfl UCTIO N HARK CNE R£M ONLY w BOXES A.B.ANO C.ANO ALL THAT APPLIES IN 8cx 0 <br /> A. TYPE OF BLfi WALL ❑ 3 SINGLE WALL WITH EXTERIOR LNER Cl 9S UNKNOWN <br /> SYSTEM 2 31NOLS WALL ❑ 4 SECONDARY CCNTAINMENT (VAULTED TAN)q ❑ 99 OTHER <br /> a. TANK ❑ 1 aAR9 STEEL ❑ .2 STANLES3 STEEL ❑ 3 FIBERGLASS ❑ 4 SrEe'1.CLAD WJ MGEACAASS RENFORCSD PLASTIC <br /> MATERIAL ❑ S CONCRETE ❑ 8 POLYVINYL.CLILOAcra7 NUM ❑ 9 TOO*/. METHANOL COMPATIBLE WIFRP <br /> {primary ratty) ❑ 9 BRCN� ❑ 10 GALVANCED STEEL 93 UMCNVOWN ❑ 99 OTHEa <br /> F71 RUBBER LINGO C:] 2 ALKYD L24ING <br /> C.1NTEaiCa ���Zzo�A <br /> 4 PHENOLIC 1.NNtNGLIKING ❑ S GLASS LINING ❑ a UNLINED 99 OTHER <br /> IS LINING MATEPLAL COMPATMU WrrH lw% METHANOL, YE3_ NO_ <br /> D.CCRRC$tCN ❑ I PCLYEYHYLENE WRAP ❑ 2 COATNO ❑ 3 VINYL WRAP ❑ a 1IgEACLASS AE1TNFORCE0 PLASTIC <br /> PROTECTION ❑ S CATwocic PROTECT;CN ❑ 9t NGVE ❑95 UNX NCWN ❑ 99 OTHER <br /> M PIPING INFORMATION CIaCLX A IFA80VEGaCtMOR U IFUNCeRGSCUNO.aOTHxAPPLxt.BLE <br /> A. SYSTEM TYPE A U r SUCTION A U 2 PRESSURE A U 3 GAAVITY A U 99 OTTER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 OCUBLE WALL A U 3 LINED TRENCH A U 93 UNVIctOWN A U 99 OTHER <br /> C. MATERIAL AND A U 1 BASE ST=—L A U 2 STAINLESS STEEL A U 3 POLYVINYL CNLCRICE(PVCT A U A FCaEAGLASS PIPE <br /> CORROSiON A U s ALUMINUM A U a CCNCRETE A U 7 STEEL'MCOATNG A U 8 Tom METHANOL COMPATIBLE WIFRP <br /> PROTECTION A U 9 GALVANIMO STEEL A U t0 CATHCOIC PROTECr'n'N A U 93 UNtGVOWN A U 99 OTHER <br /> D. <br /> L;-AX DETECTION ❑ 1 AUTCMATIC UNE LEM OE v.CTOR ❑ 2 LNE TIGHTNESS TESTING ❑ s:r 1 ML C] 99 OTHEr� <br /> VCHNTORING <br /> V.TANK LEAK DETECTION <br /> RnI VISUAL CHECK ❑ 2 UrVUMRY R£WNMtArcN ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANKGALIGWG❑ 5 GRCUNOWAlaa.VC.VrrCAWG <br /> IJO 6 TANK TESTIING ❑ T WMASTMALMONrrORWG ❑ 91 NONE ❑ 93 UNKNOWN ❑ 99 OTHER <br /> VL TANK CLOSURE INFORMATION <br /> 1.ESr.MATEO GATE LASTUSEO W4tOAYlYR) 2.ESTTMATEO CUANTITY OF Aa� rNK:gtEO Writ I <br /> S1I8STANCEr7EMAINiNCI CALLCNS 3 WAS TAI NERTMATEatAL? YES ❑ NO❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO TFfE BEST OF MY KNOWL 0G^ RUE ANQ ECT <br /> APPLICANTS NAME / '/ <br /> tNMMTEp•sle+utvaq JCATs 1 <br /> _ AA <br /> LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> (r(fG, ,(7 co® luarsr or s FACILITY T x <br /> n <br /> STATE I.D. <br /> PE.'.MITNUMBEa ! PERMITAPPROVED 8Y4CAT9 PERMIT EXPIRATION CATEE <br /> cam a {9-rrq THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPILICAT1691f4RM A.UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FOaom�a.tu <br />