Laserfiche WebLink
TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION <br /> ONE ITEM ❑ O 7 PERMANENTLY CLaSM <br /> 21NTERIM PERMIT A AMENDEDPERMIT E]6 TEMPORARY TANK CLOSURE 08TANKREMOVED Oq <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: 1 C I s� � <br /> l/YIQ Q" ,A' a FARM TANK-YES O NO _7 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY <br /> to <br /> A. OWNERS TANK IDM coo�2, B. MANUFACTURED BY: <br /> C. YEAR INSTALLED 1,3 t7c D. TANK CAPACITY IN GALLONS: 1 OOO <br /> If. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. A <br /> A. �I MOTOR VEHICLE FUEL 2 PETROLEUM B. C [:] I UNLEADED E]2 LEADED �7' I� <br /> 3 CHEMICAL PRODUCT A OIL l�DIESEL N <br /> �l PRODUCT El A GASAHOL 5 JET FUEL []6 AVIATION GAS <br /> 5 HAZARDOUS Ej 80 EMPTY [:]95 UNKNOWN Ej 2 WASTE 7 METHANOL99 OTHER(DESCRIBE IN ITEM D.BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED 6 CAS.N <br /> C.A.S.b <br /> .111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,E O <br /> A TYPE OF ❑ I DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER 099 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED A SECONDARY CONTAINMENT 0 99 OTHER <br /> B.TANK <br /> ®-1 STEELIRON 2 STAINLESS STEEL 0 3 FIBERGLASS E]1 STEEL CLAD W/FIBERGIASSRIWORCED PLASTIC <br /> yf 5 CONCRETE+{ MATERIAL ❑6 POLWINYI OIOROE 0 7 ALpMIMIM E]B 100X MET)MNOL COMPATIBLE FRP <br /> 9 BRONZE 10 GALVANIZEDSTEEL 95 UNKNOWN 99 OTHER <br /> C.INTERIOR 1RUSSUILOED ❑2ALKYD LINING 3EPDXY LINING APENOUCLKANG <br /> LINING ❑5 LASS UNING 6 UNLINED N 0-95 UNKNOWN I <br /> IS UMNG MATERIAL COMPATIBLE W17H 100%METHANOL, YES 0 NO 99 OTHER <br /> D, CORROSION ❑ 1 POLYERILENE WRAP 2TAR OR ASPHALT 3VINYL WRAP 1 FIBERGLASS REINFORCED RASRE <br /> PROTECTION El 5 CATHODIC PROTECTION 91 NONE �95 UNK"N W OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A SYSTEM TYPE ?2 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH 95 UNKNOWN A U MOTHER <br /> A U I STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE IPVC) A U A FIBERGLASS PIPE <br /> C. MATERIAL A U 5 ALUMINUM A CONCRETE A U ] STEEL CLAP W/FRP <br /> A U B I/IpM,METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 5 UNKNOWN A U N OTHER <br /> a 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 3 VADOSE WELLS P S A ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S W OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> I ESTIMATED GATE LAST USED IMO/YR) 2 ESTIMATED OUANTITV OF <br /> ] WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL' ❑YES [:jNO <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 S SIGNATURF) <br /> I � <br /> b <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JUAISDICTION N AGENCY F FACILITY ID B <br /> TANK ID R <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> NEW4i°a IfF46 A30/ <br /> PERMIT NUMBER APPROVAL DATE PERMIT EX ATION DA CHECKN PERMIT AMOUNT SURjjT. FEE CODE RECENT <br /> er: �\ <br /> FORM B(34.88) THIS FORM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FORM W,UNLESS A CURRENT FORM W HAS BEEN FILED 1 I <br /> rJ� DATA PROCESSING COPY (� <br />