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RM IBS_ `L-IrvKN1A <br /> J;) WATER RESOURCES CONTROL UNDERGROUND STORAGE TANK PROGRAMARD <br /> ANK TANK PERMIT APPLICATION INFORMATION <br /> / <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. u '�V� •4' <br /> ❑ 1 NEW PERMIT <br /> MARK ONLY <br /> ONE ITEM ❑3 RENEWAL PERMIT <br /> ❑2 INTERIM PERMIT ❑5 CHANGE OF INFORMATION <br /> FACILITYYSITE 1:1 ED 6 TEM <br /> 4 AMENDED PERMIT PERMANENTLY CLOSED TANK <br /> ME WHERE TANK IS INSTALLED PORARY TANK CLOSURE <br /> I• TANK DESCRIPTION ❑6TANK REMOV <br /> COMPLETE ALL ITEMS-IF UNKNOWN— ARM TANK-YES NO <br /> A. OWNERS TANK ID SO SPECIFY <br /> C YEAR INSTALLEDN� z <br /> B. MANUFACTURED By: 6 IQ <br /> II. TANK CO D. TANK CAPgC17Y IN GALLONS: U <br /> TENTS IF(A•I),IS MARKED,COMPLETE ITEM C.IF 3,S0 <br /> A. MOTOR VEHICLE FUEL IA-I),IS NOT MARKED,COMPLETE ITEM D. A <br /> ❑2 PETROLEUM ./O <br /> j Q 9 CHEMICAL PRODUCT ❑4 OIL C1 UNLEADED <br /> 1 PRODUCT ❑4 GASAHOL ❑ DED ❑3 DIESEL �yF <br /> 5 HAZARDOUS ❑60 EMPTY ❑95 UNKNOWN ❑ �� F+ <br /> 5,LET FUEL ❑6 AVIATION GAS <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME O 1 WASTE �7 METHANOL <br /> HAZARDOUS SUBSTANCE STORED&C.A.S. ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) <br /> All, TANK CONSTRUCTION y <br /> MARK ONE ITEM ONLY IN BOX A,B,C,&D C.A.S <br /> rl <br /> I <br /> A TYPE OF ❑ i DOUBLE WALLED ❑3 SINGLE WALLED WITH EX7ERIOR LINER <br /> SYSTEM�� SINGLE WALLED ❑4 SECONDARY CONTAINMENT El 95 UNKNOWN <br /> ❑99 OTHER f <br /> i STEEL/IRON LESSSTEEL <br /> B.TANK �� ❑1 STAIN ❑3 FIBERGLASS ❑q STEEL CLAD W/FIBERGLASS REINFORCED PU511C <br /> MATERI ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE 7 ALUMINUM <br /> ❑9 BROMZE - ❑ IB GALVANIZED STEEL- 95 UNKNOWN B 100%METHANOL COMPATIBLE Flip <br /> 99 OTHER <br /> ❑ I RUBBERLINED <br /> C. INTERIO ❑2 INING 3 EPOKYLINING 4 PHENOLIC LINING <br /> LINING ❑5 GLASS LINING 6 UNLINED <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHAM7 YES NO 99 OTHER 95 UNKNOWN <br /> �/ <br /> D. CORRO i POLYETHIENE WRAP 2 TAO OR ASPHALT ❑3 VINYL WRAP <br /> PROTE ❑5 CATHODIC PROTECTION � l NONE ❑95 UNKNOWN ❑4 Fl SS REINFORCED FUSTIC <br /> 99 OTTHERHER <br /> IV. PIPING INFOA ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A SUCTION A U 2 PRESSURE <br /> A U 3 GRAVITY q U 99 OTHER <br /> B.CONSTRUCTIO A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 5 UNKNOWN A U 99 OTHER <br /> 6 A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE <br /> C.MATERIAL J{ A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP <br /> A U' 9 GALVANIZED STEEL A UNKNOWN A U B 100%METHANOL COMPATIBLE FRP <br /> A U 99 OTHER <br /> V. L DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR B FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 9 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P 8 6 PRECISfON TESTING P 8 ] PRESSURE TESTING $ 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> TIMATED GATFyIAST 5ED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> ��A�ll////k SUBSTANCE REMAINING IN INERT MATERIAL? YES Ej NO <br /> GALLONS <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> )CANTS NAME(PRINTED S SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> /COUNTY## JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> ELI ci <br /> CU LOCAL AGENCY FACILITY IDN OVED BY NAME 4� PHONE#WITH AREA CODE <br /> 2� r—i/�s <br /> IT NUMBER P I PROVAL DATE PERMIT E% IPA ON DATE <br /> SURCHARGE AMT. FEECODE RECEIPT# BY: <br /> CHECKS PERMITAMOUNT <br /> y�I��' <br /> FORM B(3-7-Bel THIS FORM MUST BE ACCOMPANIEQBY A FACILITYISOIA A PROCESS NOGG COPY <br /> UNLESS A RENT FORMA' HASBEENFILED <br /> _ — <br />