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• STATE OFCALISTATE WATE FORMA • a <br /> ES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEMMARK ONLY ❑ 1NEW PERMIT <br /> ONE ITEM ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION <br /> ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ❑ 3 TEMPORARY TANK CLOSURE PERMANENTLY CLOSED,ON SITE <br /> 3 TANK REMOVED <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D. <br /> C. DATE INSTALLED(MO/DAVryEAR) S. MANUFACTURED BY: <br /> II.TANKCONTENTS TANK CAPACITY IN GALLONS: <br /> IF AlA.7 IS MARKED,COMPLETE ITEM C. <br /> A. ❑ 1 MOTOR VEHICLE FUEL <br /> ❑ 4 OIL B. <br /> ❑ 2 PETROLEUM C. ❑ 1a REGULAR <br /> ❑ 1 PRO <br /> 3 DIESEL <br /> BO EMPTY ❑ DUCT UNLEADED <br /> ❑ 3 CHEMICAL PRODUCT ❑ 1b PREMIUM U 4 GASAHOL ❑ e AVIATIONGAS <br /> 10196 UNKNOWN 0] 2 WASTE UNLEADED 5 S OTHER JETFUEL ED METHANOL <br /> D. IF(A-1)IS NOTMARKED, ENTER NAME OF gUB3TANCE STORED ❑ 2 LEADED ❑ <br /> ❑ B (DESCRIBE IN ITEM D. BELOW) <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,e,AND C,AND ALL THATAppLIES IN BO%D <br /> C.A.S. <br /> A. TYPE OF ❑ 1 DOUBLE WALL ❑ <br /> SYSTEM 3 SINGLE WALL <br /> 2 SINGLWITH EXTERIOR LINER <br /> ❑ E WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANI() ❑ WN <br /> B. TANK ❑ 1 13RETE <br /> ❑ BB OTHER <br /> ❑ 2 STAINLESS STEEL <br /> MATERIAL ❑ 5 CONCRETE ❑ 3 FIBERGLASS ❑ q STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> (Primer Tank ❑ 9 POLYVINYL CHLORIDE ❑ 7 ALUMINUM <br /> Y I ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL El ❑ 3 100% METHANOL COMPATIBLE W/FRp <br /> ❑ 1 RUBBER LINED 95 UNKNOWN ❑ 99 OTHER <br /> C.INTERIOR ❑ 2 ALKYD LINING ❑ <br /> LINING 11 ❑ e UNLINED 3 EPDXY LINING 5 GLASS LINING ❑ 4 PHENOLIC LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ 95 UNKNOWN ❑ 99 OTHER <br /> D.CORROSION ❑ 1 POLYETHYLENE Wgpp ❑ p COATING VES_ NO_ <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91NONE ❑ 3 VINYL WRAP <br /> ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> ❑ <br /> 96 UNKNOWNIV.PIPING INFORMATION CIRCLE A IFASOVEGROUNDOR U 99 <br /> A. SYSTEM TYPE IF UNDERGROUND,BOTH IF APPLICABLE <br /> EDOTHER <br /> A U 1 sucnoN <br /> A U 2 PRESSURE A U <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOU3 GRAWry <br /> BLE WALL A U 99 OTHER <br /> C. MATERIAL ANDA STEEL A V 2 STAINLESS STEEL A U 3 LINED TRENCH A U 05 UNKNOWN A U 99 OTHER <br /> U 1 BARE <br /> CORROSION A U 5 ALUMINUMA U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> PROTECTION A U 9 GALVANRED STEEL A U S CONCRETE A U 7 STEEL Wt COATING <br /> A U 10 CATHODIC PROTECTION A U 9 100% METHANOL COMPATIBLE W/FRP <br /> D. LEAK DETECTION ❑ 1 AUTOMAT IC LINE LEAK DETECTOR A U 95 UNKNOWN IA U gg OTHER <br /> ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MML -. <br /> V.TANK LEAK DETECTION MONITONIT ORING ❑ 99 DINER <br /> ❑❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING <br /> S TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE <br /> ❑ 95 UNKNOWN <br /> VI.TANK CLOSURE INFORMATION ❑ 99 OTHER <br /> 1.ESTIMA=O DATE LAST USED(MO/DAY/YR) 2.ESTIMATEDQUANTITYOF <br /> SUBSTANCE REMAINING 3.WqS TANK FILLED WITH <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE ANDWrATMI YES CORRECT <br /> NO E]] <br /> APPLICANT'S NAME <br /> IRRINTEG 6 SIGNATIREI <br /> DATE <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> STATE I.D.# COUNTY 0' JURISDICTION# <br /> ® � Y <br /> FAC11 IL11,IT1111 p TANK# <br /> PERMIT NUM BER O mT�T� nl <br /> PERMIT APPROVED BY/DATE <br /> DA <br /> FORM B (&90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM AN <br /> ,ULESS A CURRENT FORMA NHAS BEEN FILED. <br /> • FOROOM&119 <br />