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-^��r-uRNI� <br /> FORM `B'; PEV <br /> WATER RESOURCES CONT <br /> R <br /> TANK UNDE GROUND STORAGE TANK p OARD <br /> RFo <br /> COMPLETEASEPARA MMTA ELIC 4G IiO AM "• <br /> MARK ONLY WITH THEFOLLOWIp INFORMATION <br /> ONE ITEM 1 NEW PERMIT FORMATION FO <br /> fle <br /> 2 INTERIM PERMIT E 3 RENEWAL PERMIT R EACf{ <br /> FACILITY/SITE NAMEWHERE TpINK IS INSTALLE ED AMENDED PERMIT 6 CHANGE OF INFORMATION °""• e Z <br /> I• TANK DESC ❑6 TEMPORARY TANK CLOSURE 0 Z PERMANENTLY CLOSED TANK 10 <br /> RIPTION COMPLETE ALL. ❑STANK REMOVED <br /> A. OWNERS TANK ID# TENS- <br /> IF UNKNOWN—SO SPECIFY FARM TANK-YES NO <br /> Q YEAR INSTALLED W <br /> B. MANUFACTURED BY: w <br /> II. TANK CONTENTS <br /> I <br /> IF A.1,IS MARKED,COMPL D. TANK CAPACITY IN GALLONS: co <br /> cm <br /> A. EII MOTOR VEHICLE FUEL COMPLETE ITEM C.IF(q,T) Ig NOT MARKED,COMPLETE ITEM D. <br /> ❑3 EMICAL PRODUCT 2 PETROLEUM <br /> 4 OIL B. <br /> 5 HAZARDOUS 0 8O EMPTy ❑ � 4 GASAHDE <br /> C. <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER I4gME OF 95 UNKNOWN I PRODUCT � ❑2 LEADED <br /> 5 JET FUEL 3 DIESEL <br /> HAZARDOUS SUBSTANCE STORED g C;S.# 2 WASTE T METHANOL 99 0 6 AVIATION GAS <br /> TANK CONSTRUCTION MARK ONE I <br /> OTHER(DESCRIBE IN 17EM D,BELOW) <br /> III. TEM ONLY IN BOX q,g <br /> C,&D C.A.S.#: <br /> A TYPE OF 111 OOIRLFWALLED 0 3 SINGLEWAUFD WRH <br /> SYSTEM 02 SOW WALLED EXTERIOR LINER <br /> Li 4 SECONDARYCONTAINMENT ❑6i`UNKNOWN <br /> B. TANK 0 1 SIEBIIRON 02S1,...ou:.Is 0 M OTHER <br /> MATERIAL ❑5 COICRETE CHLORIDE 7gLUMINUM <br /> 6 ROL 3 FIBERGLASS 0 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> ❑ YWA'L <br /> 9 BRONZE 10 GAL VANZ®STEEL 06100%METHANOL COMPATIBLE FRP <br /> I RIBBER ONED 0 95 UNKNOWN ❑M OTHER <br /> C. INTERIOR 2 AU(YDL�AND 0 3 EPDXYLINING <br /> LINING ❑5GLASS UNNG O6UMI ❑4 PHENOUCLINING <br /> 11 S LINING MATSWCOMNTBLEMTH1^IEiHANOL? YES ❑ 0 9 UNKNOWN D. CORROSION � 1 POLYE7NBEWHAP �21'VIORASFHALi NO ❑99 OTHER <br /> PROTECTION 5 CATHODCPRDTECTION 91 NOTE ❑3 VINYL WRAP 4 FlBB?GLASS REINFORCED PLASTIC <br /> El 95 UNKNOWN 1:3 M OTHER <br /> IV. PIPING INFORMATION CIR IFABOVEGROUND, U IFUNDERGROUND,BOTH <br /> A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE IF APPLICABLE <br /> W A U 3GRAVITY <br /> B.CONSTRUCTION A U T SINGLE W A U 2 DOUBLE WAIL® A U 3 LINED TRENCH A U 91 NONE <br /> A U 1 STEEL/IRON A U A U 95 UNKNOWN A U gg OTHER <br /> C.MATERIAL A U S ALUMINUM A U 6 CONCRETES A U 3 POLYVINYL CHLORI E PVC 1 NONE A U 95 UNKNOWN A U 99 OTHER <br /> TEEL <br /> A U 9 GALVANIZED. A U 95 UNKNOWN A U 7 STEEL CLAD W/FRR ( ) A U 4 FIBERGLASS PIPE <br /> A U 99 OTHER A U 8 '00%METHANOL COMPATIBLE FRP NE <br /> V. LEAK DETECTION SYSTEM -E P FOR PRIMARY,OR S FOR SECO <br /> P 5 1 VISUAL CHECK P S 2 INVENTCONCILIATION P S NDARY,A PRIMARY LEAK DETECTION <br /> 3 vADDSe WELLS P SYSTEM MUST BE <br /> P S 6 PRECISION TESTING P S 7 PREBSUING P B 91 NONE S 4 ELECTRONIC MONITOR CIRCLED. <br /> P 8 95 LINK P B S GROUND WATER MONITORING WELLS <br /> VI. INFORMATION ON TANK PANENTLY CLOSED IN PLACE P $ 99 orHER- <br /> 1. ESTIMATED DA TE LAST USED(MO/YR) 2. ESTIMATED pUgN71TY OF <br /> SUBSTANCE REMAINING IN <br /> 3..WAS TANK FILLED WITH <br /> THIS FORM HAS BEEN COMPLADER PENALTY OF pERJUR I9ALLONS INERT MATERIAL? <br /> I AND TO THE BEST OF YES ❑No <br /> APPLICANTS NAME(PRINTEIURE) MY KNOWLEDGE,IS TRUEAND CORRECT, <br /> DATE <br /> LOCAL AGENCY USE ONL' <br /> COOOU�N��`TYY#��� JURISDICT AGENCY# <br /> `{� J FACILITY ID# <br /> �� TY <br /> ^ TANK ID# <br /> CURRENT LOCAL AGENCY FAC IV APPROVED BY NAME -LJ <br /> UI <br /> PERMIT NUMBE PERMIT APPROVAL DATE <br /> PERMIT EXPIRATION DATE PHONE#WITH AREA CODE <br /> CHECK# <br /> pERMII SURCHARGEAMT. <br /> FEE CODE /O <br /> RECEIPT# <br /> dYA FACILITY/SRE APPLICATION, FORM ` BY: <br /> FORM B 16-29-e61 THIS FORM MUST I A',UNLESS <br /> DATA PROCESSING COPY BRENT FORM'A' <br /> HAS BEEN FILED <br />