Laserfiche WebLink
I HIV K E AfvK PtkMlIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. �� • <br /> MARK ONLY 1 NEW PERMIT D RENEWAL PERMIT <br /> ONE ITEM2 INTERIM PERMIT 5 CHANGE OF INFORMATION / PERMANENTLY CLOSED TANK <br /> 1 AMENDED PERMIT 6 TEMPORARY TANK CLOSURETANK REMOVED Q <br /> FACILITYVSITE NAME WHERE TANK IS INSTALLED: <br /> 98 TANK-YES NOD <br /> L TANKDESCRIPTION COMPLETE ALL ITEMS.IF UNKNOWN—SO SPECIFY <br /> . OWNERS TANK ID Y 1 O <br /> B. MANUFACTURED BY: <br /> C. YEAR INSTALLED <br /> D. TANK CAPAGTY IN GALLONS: <br /> II- TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D A <br /> A. MOTOR VEHICLE FUEL 2 PETROLEUM 8. C ❑ I UNLEADED Z LEADED 'J <br /> �3 CHEMICAL pgOq/CT I OIL 0 9 DIESEL N <br /> LVJ ' PROOUCT ❑4 GASAHOL 05 JET FUEL E]6 AVIATION GAS <br /> 5 HAZARDOUS 0 BD EMPTY 0 95 UNKNOWN D 2 WASTE D 2 METHANOL n N OTHER IDESCEIRE IN ITEM D, <br /> O. IF NOT MOTOR VEHICLE FUEL ENTER NAME Of BELOW( <br /> HAZARDOUS SUBSTANCE STORED A C.A.S.K <br /> KIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A.B,C,i D CAS.K. <br /> A. TYPE OF ❑ 1 DOABLE WALLED Lj 7 SINGLE WALLED NTH EXTERIOR LINER %IXE(NOWN <br /> SYSTEM Z SINGLE WAELEO I SECONDAINCONTAVBIENT <br /> 99 OTHER <br /> B.TANK ❑ 1 STEEL/NON O 2 STAINLESS STEEL 0 0 FIBERGLASS 1 STEEL CLAD W/FIBERGLASS RENFORCED ELASTIC <br /> MATERIAL ❑5CONOETE 6FaYVIWLOtOROF 01 ALUMINUM BLao,METNWOL COMPATIBLE FRP <br /> 10 <br /> 9 BRONZE GALVANIZED STEEL O%UNKNOWN 99 OTHER <br /> C.INTERIOR ❑ 1RUBBER LINED 2AUKYD LINING _... ❑ 9EPDXY LINING 1PHENOLIC LINING <br /> LINING ❑ 5 GLASS LINING El 61MIFED I I ❑Ss UNKNOWN <br /> ISUMNGWIERALCOMPATIBLEMTH100KMETK No,, DYES [—] NO D99 OTHER <br /> D. CORROSION L_j I POLYETNLENEWRAP Lj 2 TAR ORASPHATT .__.O 7 VINYL rFIBERGPROTECTION LASS REINFORCED PIA9Ilc <br /> 5 CATHODIC PROTECTION El 91 NDN 1:1 95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE <br /> A U e GRAVITY <br /> Y <br /> LINED <br /> REEA U 99 OTHER <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U t DOUBLE WALLED A U 9 LINED TRENCH A U 95 UNKNOWN <br /> A U 1 STEEL/IRON A U 99 OTHER <br /> C.MATERIAL A U 2 SI AINLES$SiEFI A U J POLYVINYL CHLORIDE(PVC( A U K FIBERGLASS PIPE <br /> A U 5 ALUMINUM A U 6 CONCRETE A U I STEEL CLAD W/FNP <br /> A U 9 GALVANIIEDSILEL A U 95 UNKNOWN A U A 100%METHANOL COMPATIBLE FNP <br /> A U 99 OMEN <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY.A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P 5 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S ]VADOSE WELLS P Y A ELECTRONIC MONITOR <br /> P S 6 PRECISION TESTING P S I PRESSURE TESTING P 5 91 NONE P S S GROUND WATER MONITORING WELLS <br /> P Y 95 UNKNOWN P 5 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> I ESTIMATED DATE LAST USED IMO/YNR — — <br /> t ESTIMATED OUANIGY OF t WAS TANK EILLEO WITH <br /> SUBSTANCE REMAINING IN INERT MATERIAL, <br /> - - ceuoes YES ED ND <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT S NAME(PRINTED A SIGNA IIIHI <br /> 0AjE!•. <br /> LOCAL AGENCY USE ONLY <br /> • COUNTY E JURISDICTION <br /> � AGENCY A FACILITY ID E <br /> ® � TANK 10 N <br /> CURRENT LOCK AGENCY FACILITY ED Y - ----- - --- _ <br /> C3 <br /> APPROVED BY NAME PHONE 0 WITH AREA CODE <br /> PERMITNUMBER - - <br /> PERMIT APPROVAL DATE PERMIT"MRATION DATE -- <br /> CHECK• PERMIT AMOUNT SURCHARGE AMT. - <br /> FEECOOE RECEIPT BY: <br /> FpNMe pI-Be) THIS FORM MUST BE ACCOMPANIED BTAFACILIIT/SITE APPLICATION, FORM 'A',UNLESSACUHRENT FORMA' HAS BEEN FILED <br />— --- DATA PROCESSING COPY <br /> 4 <br /> u1Ci::wT,1SSTi:. .9.r1"e:�.iti6MY.tmNI►.,eatrla....ti,�:...e,:c,::....,..; a.._„_..., :.,q-,,,,..-.,,._.-:m....._r.�_ <br />