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• ' D 66VURC+s 4(�rATE4aAUi `� ••• °�' STATE WA OLS D UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMA�ENSITE ONE ITEM Jl��I 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE /❑� 8 TANKCR— DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 6 Zj� l/fI, /11,1¢7/51 .3 Ael I. TANK DESCRIPTION COMPLETE ALL ITEMS-SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.S B. MANUFACTURED BY: co r C. DATE INSTALLED(MO/DAY/YEAR) I I D. TANK CAPACITY IN GALLONS: � r II.TANK PONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ taUNLEA ED REGULAR 3 DIESEL ❑ g AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 4 GASAHOL lb ❑ 7 METHANOL UNLEADED5 JET FUEL j3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE C:] 2 LEADED J 99 OTHER (DESCRIBE IN ITEM 0. BELOW) 0. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.r: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8,AND C,AND ALL THAT APPLIES IN BOX 0 A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER S. TANK ❑ t BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MAT ERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED 172 ALKYD LINING F73 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR LINING F75 GLASS LINING ❑ 6 UNLINED F795 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.80TH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 10094 METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 INTER IAl 99 OTHER MOn ❑ NITORING V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) I 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES [:] NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED 8 SIGNATURE) 7 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# • L� � n p 3 a l d PERMIT NUMBER PERMIT APPROVED BY/OATE ( PERMIT EXPIRATION DATE FORM 8 (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION+FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR=48•R4 f.