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Ir I A I t U r VAL I h U K N I* WATER RESOURCES CONTRdaOARD FORM /B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR FAru TAWIr MARK 3HLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT HANGE OF INFORMATION El7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT El AMENDED PERMIT g�6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED 9 FACILITY156'o E NAME WHERE TANK IS INSTALLED: f FARM TANK YES ❑ NO ❑ AWI! nrQROlnrl�u •- • --• .....� 1 w.. I.VMrLr Ir ALL ITEMS -IF UNKNOWN —SO SPECIFY A. OWNERS TANK ID # B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF /A_11- IS MARKFn enuol Lrc IV.— A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. 'r C. ❑'I UNLEADEDc 11❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL. ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF HAZARDOUS SUBSTANCE STORED & C.A.S. # C.A.S. #: vlv01 nU%, I IVIV MARK ONE ITEM ONLY IN BOX A_ B_ C_ An A. TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER B TANK F-]1 STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC . MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE I ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FRP U 1 STEEL/IRON ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR F-11 RUBBER LINED ❑ 2 ALKYD LINING El3 EPDXY LINING E]4 PHENOUC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINED A U 8 100% METHANOL COMPATIBLE FRP ❑ 95 UNKNOWN A ❑ IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION riR(:I F A IF ARnvL' nnni mn III is i uincal. a r. V. A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL. A U 95 UNKNOWN A U 99 OTHER LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST RF rIRr1 Fn P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE- P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED (MONM 2. ESTIMATED QUANTITY OF 9 WAS TANK FILLED WIT" -- — SUBSTANCE REMAINING IN GALLONS INERT MATERIAL^ YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLFDC F IS TRI IF AAIn rnRAGrT APPLICANT'S NAME (PRINTED 8, SIGNATURE) DATF .. LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # m CURRENT LOCAL AGENCY FACILITY ID # PERMIT NUMBER CHECK # I PERMIT AMOUNT AGENCY# PERMIT APPROVAL AMT FACILITY ID # SY NAME PERmrrExpopATiON DATE FEE CODE I AMWEIPT # TANK ID # PHONE # WITH AREA CODE Br: FORM B (3-7-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITYMM APPLICATION, FORM 'A', UNLESS A CURRENT FORM'A' HAS BEEN FILED - - nATA fln-