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STATEOFCAUFOIO*A a STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION7 PERMANENTLY CLOSE NSITE ONE REM ❑ 2 INTERIM PERMIT F74 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 2k B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: U44 !>Feel I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.i uu B. MANUFACTURED BY: C. DATE INSTALLED(MQOAYNEAR) D. TANK CAPACITY IN GALLONS: CljV V� ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. �(! 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. laU E EADED 4 GASAHOL ❑ 6 AVIATION GAS A. r❑' 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ 1bUNELMIUM 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 68 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 90 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.8: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALL THAT APPLIES IN BOX D AND IL JYyPE.DF ❑ I DOUBLE WALL f73 SINGLE WALL WITH EXTERIOR LINER yi. .,..,❑ 95 UNKNOWN $PSTEM j:;J-2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDYANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL F73 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC MATERIAL 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PUmvyTARk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING (❑ 3 EPOW LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING6 UNLINED r795 UNKNOWN ❑ 99 OTHER LINING 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 W91 NONE ❑ % UNKNOWN ❑ S9 OTHER E.SPILL AND OVERFILL SPILLDONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION U PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION N U 1 SINGLE WALL A U 2 DOUBLE WALL A U3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 RARE 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*COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 96 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONR MITERSTITIA E::] 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING X 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTILlAjEO D TE LAST USED(MO/DAYAW) 2.ESTIMATED QUANTITY Of per. 3 WAS TANK FILLED WITH YE V(„ SUBSTANCE REMAINING --CJ GALLONS INERTMATERIAL? ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY URY AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME IDATE IPPoMED43KtNATUREI /', i// �� A..rr.J. 37-17 LOCAL AGENCY USE ONLY lL THE STATE 1.0.NUMBER IISS C OSED OF THE FOUR NUMBERS BELOW I/f COUNTY# JURISDICTION# FACILITY* TANK♦ STATE I.D.# MI 32W k43blql9lrj PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE '�•� FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BE FORXIMM �/ v