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STATEOFCAUFORMA <br /> ST ATE INA TIER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 1 NEW PERMIT 1-1 3 RENEWAL PERMIT 5 CHANGE OF !NFORMA7ICN <br /> j 1 7 PERMANEN%Y CLcSED, <br /> ONE ITEM 2 iNTEAIM PERMIT 4 AMENDED PERMIT i TEMPORARY TANK CLOSURE <br /> 3 -ANK ;;EVCVED <br /> 'BA OR FACILITY NAME WHERE TANK IS INSTALLED: A92_cp lF:=ic_ �C). <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF JNKNOWN <br /> A. OWNER'S TANK t.0.* !L_u Pj L_- 1 3. MANUFACTURED 3Y: <br /> .`TATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY N GALLONS: 1-7 <br /> -11.TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. <br /> a. ,rl VICTOR VEHICLE FEEL -7 4 OIL C. <br /> 3. REGULAR 3 DIESEL <br /> UNLEACED <br /> i PETROLEUM 77 30 EMPTY i GASAHOL <br /> 2 PRODUCT i PREMIUM <br /> !b =4 <br /> UNLEACEO 5 :IE7-UEL <br /> 3 CHEMICAL PRCOUCT 95 UNKNOWN 2 WASTE I 77 2 LEADED 99 OTHER (DESCRIBE 'N ITEM 0. 9ELOWI <br /> 0. F!A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED CAS.s: <br /> 11+ <br /> 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN 130XES A.3.AND C.AND ALL THAT APPLIES IN BOX 0 AND E <br /> A, TYPE OF DOUBLE WALL _7 3 SINGLE WALL 'WITH EXTERIOR LINER <br /> 95 UNKNOWN <br /> SYSTEM 4 2 SINGLE WALL SECONDARY CCNTAINMENT (VAULTED TANK) 49 OTHER <br /> 3. TANK 1 3ARE STEEL 2 STAINLESS STEEL '!7,.fe3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> - CONCRETE S POLYVINYL CHLORIDE 7 ALUMINUM 3 ',OC?Y. METHANOL COMPAr9L='NfF:;P <br /> MATERIAL , , 3 - I <br /> (Primary Tank) '_7 9 BRONZE r^ 10 GALVANIZED S—..:-:L 95 UNKNOWN gg OTHER <br /> I RUBBER LINED 2 ALKYD LINING <br /> C.INTERIOR 3 -EPDXY �.:NING 4 3L-ENOLC LINING <br /> 5 GLASS LINING —1-l"i UNLINED 95 UNKNOWN <br /> LINING 99 OTHER <br /> LINING <br /> LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES 140 1 <br /> O.CORROSION I POLYETHYLENE WRAP 2 COATING 3 VINYL WRAP =',BERGLASS REINFORCED MLASTIC <br /> PROTECTION J 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN 99 OTHER <br /> =.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GRCUNO OF; U 'F','N0cRGROUN0.30TH IF APPLICABLE <br /> A. SYSTEM TYPE A U I SUCTION A )2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> 3. CONSTRUCTION A(n, SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH <br /> A U 35 UNKNOWN A U 39 <br /> C. MATERIAL AND A U i 3ARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)AU , FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELWICOATING A U 8 100% METHANOL CCMPAr;BL__W,FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHCOIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION ��:_ AUTOMATIC LINE LEAK DETECTOR �2 LINE TIGHTNESS TESTING I INTERSTITIA <br /> MONITORING 99 OTHER <br /> V. TANK LEAK DETECTION <br /> - 1 VISUAL CHECK f7 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING _7 4 AUTOMATIC TANK GAUGING I 5 GROUND WATER MCNITOR ING <br /> — 6 TANK TESTING '::�: 7 INTERSTMALMONfTOR ING 91 NONE 1 i 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> I.=ST;MATED GATE LAST USED(MO/DAY/YR) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING YES 7— '40 <br /> GALLONS I INERT MATERIAL? <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CCPPEC T <br /> APPLICANT'S NAME DATS <br /> pqINTED d SIGN TURE) <br /> Z-V 9z_l <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FONUMBERSBELOW <br /> COUNTY* JURISDICTION x FACILITY 9 TANK s <br /> STATE 1.D. <br /> 16 1-� 'o a <br /> ,'E.;MIT,14UMBE.R PCIRMIT APPROVED BY/OATE I PERMIT EXPIRATION DATE <br /> FORM 9 r7-911 THIS FORM MUST BE ACCOMPANIED BY A PERMrr APPLICATION FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br />