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• ++ ` v r ♦,�yL,��-V f i WATER RESOURCES COBOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY 1 NEW PERMNT ❑3 RENEWAL PERMIT [:]S CHANGE OF INFORMATION ❑7 PERMANENTLY CLOW TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOlll VED FACILITY/SITE NAME WHERE TANK IS INSTALLED. ? ARM TANK-YES❑ NO ❑ I. TANKDESCRIPTION COMPLETE ALL ITEMS-OFUNKYOWN—'SoSPECIFY to A. OWNERS TANK IDM B. MANUFACTURED 8Y: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: F-a I1. TANK CONTENTS IF(A.1).IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. pp 7pF--1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. /D C ❑ I UNLEADED ❑2 LEADED ❑3 DIESEL CHEMICAL PRODUCT ❑♦OIL ❑ 1 PRODUCT /f ❑M GASAHNri ❑5 JET FUEL ❑6 AVIATION GAS El S HAZARDOUS ❑BO EMPTY ❑95 UNKNOWN ❑2 WASTE ! ❑ T METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED b CA.S.M: Z � - C.A.S.•: /3 x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A TYPE OF // ❑1 DOUBLE wam ❑3 SINGLE WAWALLEDWITH W61%W61%LINER ❑95(MMOMN SYSTEM E]2 SN1(ti,E WALtM ❑I SEC WW(y CWA##*W ❑99 OTHER B.TANK I SiEE imm E]2 STAINLESS OR ❑3 FIBERGLASS ❑t STEEL CIAWIRBERGLASS REPIFORCED PLASTIC MA77ER �� ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALLW M ❑6 ton ETINNOLCOMPATIRERIP ❑9 BRONZE ❑10 GALVAMZED STEEL ❑95 UNKNOW+( ❑99 OTHER C INTEAKNi ❑1 Rum Los ❑2 AU(YDMW ❑3 DOW M4 ❑1 mIEIgDUCUNNIG UNI /6 ❑S MASS UW G ❑6 UILINED ❑95 LM6O(OYM ❑SL"GMATERAICOMPATIBLEwrrH(6011LEnwioL zoo YES ❑ND ❑99 DIM D.CORK 1 POL1¢t}LBIEMIRAP ❑2 TMORASPNKT ❑3 WfLWRAP ❑4 FsmaAss(EfFQR=RASTIC Pit" ❑S GTHDDICI%TECnM ❑N NONE ❑%UHMO(DWN ❑99 am IV. PIPING INFORMATION CNTCLE A 1F ABOVE GROUND. U IF UNDERGROUND,BOTH W APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PARE A U 3 GRAVITY A U 99 OTHER IL A U 1 SMIGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEE. A U 3 POLYVINYL CHLORIOE(PVC) A U FIBERGLASS PIPE C.MATERIAL �/ A U 5 ALL*mNum A U 6 CONCRETE A U 7 STEE.GLADWIFRP A U a 100%METHANOLCOMPATI9LEFRP A U 9 GALVANIZED STEE. A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY-OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 1 VISUAL CHECK ► = 2 INVENTORY RECONCILIATIOm ► t 3 VADOSE WELLS P t •ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS d PRECtBHOM TESTMq P i z PRESSURE TESTING P SI 91 NONE P a 96 UNKNOWN P SI 99 OTHER I�VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1 IMATEO DATE LAST USED(MO/YRI TW OUANTm OF AS TANK BILLED WITH ANl3E REMAINING IN r MATERIAL? ❑YES ❑NO GALLOtq THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PER)URY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED A SIGNATURE) DATE LOCAL AGENCY-.USE-ONLY JURISD1CT10111 AGENCY i fACRJTY ro• �. TANK ro A Fl LL L�,AL AGENCY F, IDI Q NAM! mm•WITH"m COD! - AL DA �••R tHTPIIlAt1oN L4i1►Tt -Pop 11 orlt ....... x.--