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ANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. i <br /> MARK ONLY ❑ I NEWPERMIT O RENEWAL PERMIT <br /> ONE ITEM ❑5 CHANGE OF INFORMATKX/ gMANENTIY CLOSED TANK <br /> 2 <br /> IN <br /> PERMIT /AMENDED PERMIT <br /> 6 TEMPORARY TANK CLOSURE B TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY FARM TANK-YE NOE] <br /> A. OWNERS TANK IDR to <br /> 92/1 1 B. MANUFACTURED BY: <br /> C. YEAR INSTALLED <br /> D. TANK CAPACITY IN GALLONS: <br /> II. TANK NTENTS IF(A1),11 MARKED,COMPLETE ITEM C.IF(Al),IS NOT MARKED,COMPLETE ITEM O. A <br /> A. I MOTOR VEHICLE FUEL [:j2 PETROLEUM N <br /> B' C. ❑ I UNLEADED �2 LEADED ��. <br /> D CHEMICAL PRODUCT �1 OIL ��7/, ❑7 DIESEL <br /> Ly1 ' PRODUCT ❑/GASAHOL 5 JET FUEL 6 AVIATION GAS N <br /> 5 HAZARDOUS BO EMPTY 95 UNKNOWN 2 WASTE i METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NO7 MOTOR VEHICLE FUEL ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED 6 C.A.S.I <br /> .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C.a D C.A.S.R. <br /> [FL ❑ I UOLIBIE WALLED Lj J SINGLE WALLED NTH EXTERIOR LINEN 0%UacNOWN <br /> M 2 SINGLE WALLED O 1 SECOMMgfCONTAINMENT <br /> 99 OTHER <br /> I STEEL/MON 1 STNNUS9 STEEL 7 cBEgG1A99 �1 STEEL CLAD W/FIBERGLASS REmoRCED MASTICIA ❑5 CONCRETE D 6 POLYVINYL CH DROP 7 ALUMINUM L 1010%METHANOL COMPATIBLE FRP <br /> 9 BRONZE 10 GALVANIZEDSTEU 11%UNKNOWN 99 OTHER <br /> C. INTERIOR I RIBSERLINEO ❑2 AIM UNWG -- FF-'�� <br /> LINING ❑ 5 GLASS LINING I_I J EPDXY LINING 25 UNKNOW LINNG <br /> 6 UIILIMO I I �%UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH IW►METNANOLT 0 YES 0 NO D 99 OTHER D. CORROSION L_j I POLYETILUE WRAP L_j 2 TAR OR ASPHALT 0 J VINYL WRAP D 1 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 05CATHODONIOTECTON 09INONE 95 UNKNOWN 0 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM <br /> ITM A U I SUCTION A U 2 PRESSURE A U ]GRAVITY <br /> _ A U "OTHER <br /> B.CONSTRUCTION A U 1 SINGLE WALLED • U 2 DOUBLE WALLED A U ]LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> A U ISTEEL/IRON A U 251AINLESS STEEL A U ]POLYVINYL CHLORIDE(PVCI A U AFIBERGLASS PIPE <br /> C. MATERIAL A U S ALUMINUM A U 6 CONCRETE <br /> A U 7STEEL CLAD W/FHP A U BIVBXMEinANOL COMPATIBLE FNP <br /> A U 9 GALVAN12E0 SREL A U 95 UNKNOWN A U %OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S ] VADOSE WELLS P S K ELECTRONIC MONITOR P S S G110UNO WATEN MONITORING WELLS <br /> VI. INFORMATION ON <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 5 91 NONE P S 95 UNKNOWN P S NO THER <br /> TANK PERMANENTLY CLOSED IN PLACE <br /> E77777— INERT <br /> ESTIMATED DATE LAST USED IMO/URI <br /> 2 ESTIMATEDO FMAINI OF <br /> GI 1 WAS LANK ER LED WITH <br /> SUBSTANCE Hf MMNING IN INERT MATERIAL <br /> GALLONS E]YES D NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME IPRINiFO A SIGNn1UH1'I <br /> D E!•. <br /> 1 � <br /> LOCAL AGENCY USE ONLY <br /> C�COOUTN(T.Y{# JURISDICTION AGENCYR <br /> FACILITY ID q TANK 10 R <br /> CURRENT LOCAL AGENCY FACILITY 10 <br /> APPROVED BY NAPE PHONE 1 WITH AREA CODE <br /> PERMIT NUMBER — - PERMIT APPROVAL DATE <br /> PERMIT ESMgATgN PATE <br /> CHECK. PERMIT AMOUNT SURCHARGE AMT. FEE CODE <br /> RECEIITE BY: <br /> FORMBI3-7-88) TMIS FORM MUST BE ACCOMPANIED BY AFACILITY/61TE APPLICATION, FORM 'A',UNLESSACURRENT FORM-A' NAS BEEN fM.EO <br /> DATA PROCESSING COPY <br />