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axo I tH RESOURCES CONTRAOARD <br /> FORM 'B': UNDERGROUND STORAGE TANK PROGRAM <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANOE OF INFORMATION 07 PERMANENTLY CLO TANK <br /> ONE ITEM / ❑2INTERIM PERMIT ❑A AMENOEDPERMR ❑6 TEMPORARY TAN(CLOSURE ❑6 TANK REMOVED 2 �2 <br /> fACILTTY/eITE NAME WHERE TANKMINSTALLED: ARM TANK-YES❑ HO El <br /> 1. TANK DESCRIPTION COMPLETE AL ITEMS-IF UNKNOWN—BO SPECIFY 10 <br /> A. OWNERS TANK ID N B. MANUFACTUREO BY <br /> C. YEAR INSTALLED 0. TANK CAPACITY IN GALLONS: 8 ~ <br /> F-A <br /> 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A_1),IS NOT MARKED,COMPLETE ITEM D. co <br /> A. ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM 8 /D C ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL N <br /> 3 CHEMICAL PRODUCT ❑A OL El 1 PRODUCT // ❑M GASANO 0 5 JET FUEL 0 6 AVIATION GAS <br /> cl 5 HAZARDOUS ❑60 EMPTY 0 95 UNKNOWN 0 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME DEC <br /> HAZARDOUS SUBSTANCE STORED A CAS.E _ C A'S,N: <br /> .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOT(A,D,C,A D <br /> A TYPE OF ❑ I OOl1BlE WAl1ID ❑7 SHOE WAl181MMF7RFR'.ML UNDI ❑99 twmm <br /> SYSTEM 2 SNOEWNLB) ❑A SECODARYCONTMAENT ❑99 OTHER <br /> 1 STEEUFON ❑2 STM-M STEEL F-1Oki1G 3 ROM= ❑ A STEEL CLAD WMIERDAS REWORCFO PLASTIC <br /> S' MAS :'E_ ❑5 CCNO EIE ❑E POLYWYL OADFOE ❑ 7 ALU OIM I L 1004 WRIAN LODWATI LE RIP <br /> ❑9 BRDNZE ❑10 GALVANZHI STEEL ❑95 UNKNOWN ❑99 OBER <br /> El RUBORLIED E]2 AU(YOU 04 ❑3 EPDICILNNO [:]4 PHENO1CUIM <br /> O U"INTERIOR <br /> �� 0 6OU NS W�TSA/L ORIPATr�MM IW6 wT 4ROt 0 0 YES [:] NO a 99 OTHER <br /> D.CO 1 POLYETHBEMW ❑2 TAA OR ASPHALT ❑3 WMMOP ❑A FEERDUM REMOAn RASTIC <br /> Pftoncnolr ❑5 CATNOOCPROTF-"m ❑R NONE ❑95 LM010NN ❑99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNPERDROUND,BOTH WAPPUCABLE <br /> A SYSTEM TYPE A U I SUCTION A U Z PRESSURE A U 3 ORAVIIY A U "OTHER <br /> 4 A U I SINOLE WALLED A U 2 DOUBLE WAILED A U 3 UNED TRENCH A U ISUNKNO'AN Au 99 OTHER <br /> ////������'���,pppp,''''WWYY A U I STEMIRON A U 2 STAIN ESSSTEEL A U 3 POLYVINYLCHLORIOE(PYGT A U A FIBERGLASS RAPE <br /> GMATERIAL A U 5ALlM.NUM A U ECONCRETE A U 7STEELCLAD WIRIP A U K10011METHANOL COMPATIBLEFRP <br /> 0 <br /> A U A GALVANIZED STEM A U M UIMNgNM A U W OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,DR 8 FOR SECONDARY,A PRIMARY LEAF(DETECTION SYSTEM MUBT BE CIRCLED. <br /> Ll 1 1 1 VISUAL CHECK P A 2 INVENTOM RECOHCILATKk! P M 3 VADOSE VYMIS P A A ELECTRONIC MONITOR P A S OROUNU WATFA MONRORNO WELLS <br /> S PRECISION TE97w4 P A T PRESSUWIE TESTING P A 91 NONE P A 95 UNKNOWN P A 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1 NMTEO DATE LAST USED(MOZYR) I ZASTIMATEDOUANTMOF I LyYASTANI(EKLEDWITH <br /> !/ AHCE REMAIN9Ki IN OAILONA � MATERIAL? El <br /> YES E] NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. <br /> APPUCANM NAME(PRINTED A SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> 0 N jUE"SO#cY S -AGENCY• 2 FACILITY 10 E ��- TANK ID F <br /> 3 E I 1 ,� k ILI <br /> ►QCAI AOOI(,Y FACSIIY b MAIM F WTTH AREA CODE <br /> FBRIMr.IAUARAMR i'P;. ADA l w"f m% T" <br />