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Y tlal,r "' •�•• v •� IYAIEH RESOURCES CONWL BOARD <br /> FORM 'B': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> TANK TANK PERMIT APPLICATION INFORMATION ' <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY ❑ I NEW PERMIT ❑J RENEWAL PERMIT ❑5 CNA CA OF r1FORMATgN �RMANENTIY LO TANK <br /> ONE ITEM ❑2 INTERIM PERMIT ❑1 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑6 TANK RE 0 <br /> FACILITY/SITE NAME WHERE TANK M INSTALLED. MM TANK-YES 0 <br /> ❑ NO <br /> I. TANK DESCRIPTION COMKETEALLITEMS-IF UNKNOWN—'SO 4clFy o <br /> A. OWNERS TANK 10 N fD <br /> . MANUFACTURED EK <br /> C. YEAR INSTALLED TANK CAPACITY IN GALLONS <br /> 11. TANK CONTENTS IF(A.1).IS MARKED.COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM O. tip <br /> A ❑ I MOTOR VEHICLE FUEL ❑2 PETROLEUM B /D C ❑ I UNLEADED ❑2 LEADED ❑T DIESEL N <br /> ❑ J CHEMICAL PROOUCT ❑1 OIL El PRODUCT ❑1 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS <br /> 0 5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ I METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM 0.BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&CAS.N, /� <br /> - C.A.S.N; �3 <br /> x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,Ci)&D <br /> A.TYPE Of ❑ I DOUBLE WAVED E] IM 3 SINGLE WANN CaUt%LINEA E] CI 95 Um"M <br /> SYSTEM�❑2 S*W Wkin ❑1 SECONDARY CONTA 4"T ❑99 op" <br /> r I STEEURON ❑2 STAINLESS STEN E]3 FIBERGLASS 4 STEEL CLAD WIFMERMASS REINFORCED MASTIC <br /> TIIA�TER 5 CONCRETE ❑6 POLYVIIYLOHLoFNl7E ❑ 1 ALLAH" Hl 100%METIIAiIOL0DWAT8LEFRP <br /> ❑9 BRONZE ❑to GALVANZEDSTER ❑95 UN(NOIMN E119 GTHEA <br /> C WTEF ❑ I RUBBER Lm ❑2 MM LINING ❑3 EPDXY LMC ❑N PHENOLIC INK <br /> UNI // ❑5 M=LP" ❑6 tINLI NED ❑16 LA`N ohw <br /> ll ❑IS LIOG MATDW OOLIPATNU mm 10011 wTT vazop YES ❑No ❑99 ona <br /> D.(Opp I POIYETHLBE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑N F89 ASS FlEft ORCED MASTIC <br /> ❑S CATT1001C M10 WnM 0 91 NDE ❑95 L2N HOWN ❑!!OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UW?E%ROUND.BOTH M APPLICABLE <br /> A.SYETEII TYPE M A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U "OTHER <br /> 0. )CTKWA U 1 W4mE WALLED A U 2 DOUBLE WALLED A U 3 UNEDTRENp/ A U N6 UNKNOWN A U oo OTHER <br /> A U 1 STEEL/IION A U 2 STA"-ESS STEEL A U 3 POLYVINYL CMORIOE(►VCI A U NI R8ERULASS pwE <br /> C.MATSA U 6 MAJANNUM <br /> A U t CONCRETE A U 7 STEEL CLAD W/FAP A U t f00'%ME'TNIANNOL COMPATIBLEFRP <br /> 0 A U N GALVANIZED STEEL A U 96 UNKNOWN A U OSI OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE p FOR PRIMARY.OR S FOR SECONDARY.A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> G[�f I �CHECK • t 2 INVENTORY RECONCILIATION P t 3 VADOSE WELLS ► • I ELECTRONIC MONITOR • t 6 GROUNO WATER MONITORING WELLS <br /> 6 PAECLSION TE8TMq ► • T DRE TESTING • • 91 NONE • t 95 UNKNOWN • • 9Y OTHER <br /> �i VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1 NdATEO DATE LAST USED(MO/YR) r FATED OUANTM OF TAM kK)-ED WITH ". <br /> ANCE REMAINNJG IN GALI.00M <br /> MATERIAL? <br /> ❑YES [:] No <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE ANO CORRECT. <br /> APPUCANTS NAME(PRMRED t SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> S JURISDICTIONS AGENCY• 2 FACXnY ID• �.� TANK ID. <br /> L;*U.AOSNCY IACMT ID <br /> ppl1jrC! - 1. � ►IIONII t tlrtTll AS"COM <br /> P ft779= <br /> MUmgiA DA hlINNTT 93WMMTWN MATE <br /> Y ( � <br />