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I AIVK AAriK PtHMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY ❑ I NEW PERMIT 9 RENEWAL PERMIT 0 5 CHANGE OF INFORMATIONc•D T <br /> ONE ITEM 0 2 INTERIMPERMIT T PE NENTLY CLOSED TANK <br /> 1 AMENDED PERMIT 0 6 TEMPORARY TANK CLOSURE TANK REMOVED Q <br /> FACILITY/SITE NAME WINE TANK IS INSTALLE7. Y r <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS.OF UNKNOWN—STO—SPECIFY FARM TANK-YES NO �1 <br /> A OWNERS TANK ID E / t O <br /> D. MANUFACTURED BY: L - <br /> C. YEAR INSTALLED <br /> O. TANK CAPACITY IN GALLONS. <br /> II. TANK CO ENTS IF(A 1) 1S MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A <br /> A. MOTOR VEHICLE FUEL f—1 2 PETROLEUM TV <br /> B. C. 0 1 UNLEADED 0 2 LEADED DIESEL <br /> ED 9 CHEMICAL PRODUCT O/ OIL F. <br /> 5 HAZARDOUS I{�' PRODUCT ED 1 GASAMOI ❑S TET FUEL �6 AVIATION GAS N <br /> Q SO EMPTY ED 95 UNKNOWN ED 2 WASTE ED /METHANOL ED 99 OTHER(DESCRIBE W ITEM D.BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,E TER NAME OF <br /> HAZARDOUS SUBSTANCE STOR 6 C.A.S.6 <br /> C.A.S.A. <br /> All. TANK CONSTRUCTI MARK ONE ITEM ONLY IN BOX A.B,C.6 D <br /> A TYPE OF ❑ ' DOUBLE WALLED ]SINGLE WALLED MTN EXTERIOR UNER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED 1 SECON ARYCONTNNMENT <br /> 99 OTHER <br /> EEUIROK <br />} B MATERIAL O S STCOIICIUE 2 STAINLESS STEEL J FIBERGLASS1 STEEL CLAD W/fIBERCAASS REIIFORCEDRASTC <br /> 6 POLYVINYL CHLORIDE 1:1 /ALUMINUM ED 110011 METHANOLCDMPANBLE FRF <br /> 9 BRONZE 10 GALVANIZEDSTEEI O 95 UNKNOWN 99 OTHER <br /> C. INTERIOR 1 RUBBER LINED KYD LINING ❑J EPDXY LINING ED 1 PHENOUCLEMNG <br /> LINING ❑5 CLASS LINING 06 ND 1 1 ❑95 UNKNOWN <br /> ED IS LINING MATERIAL COMPATIBLE WIN I METHANOL, ❑YES ED NO ED 99 OTHER <br /> 0.CORROSION ❑ I POLYETIUENEWRAP L]2 TAR T ._._.❑J VWVL WRAP 1 FIBERGLASS REWORCED PLASTICPROTECTION 5 CATHODIC PROTECTION91 NONE <br /> ED 95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE UND. U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A U I SUCTION A U 2 PRE RE <br /> _ A U 7 ED T A U 99 OTHER <br /> B.CONSTRUCTION A U I SINGLE WALLED A U T DMJBL WALLED A U ]LINED TRENCH A <br /> U 95 UNKNOWN U 9 POLYVINYL A U 99 OTHER <br /> A U I STEEL/IRON A U 2 SIAINLE STEEL A YVINYL CHLORIDE <br /> IPVCI A U A FIBERGLASS PIPE <br /> C. MATERIA( A U 5 ALUMINUM A U 6 CONCRETE <br /> A U 7STEELCLADW/FRP A U B IOD%METNANOLCOMPAIIBLEFHP <br /> A U 9 GALVANIZED SILEI A U 95 UNKNOWN A U 99 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 21NVENtOWRECONC,L'Al'ON P S 9 V SE WELLS P S I ELECTRONIC MONITOR P S S GROUNDWATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSUHE IESTING <br /> P Y 91 NO P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED I PLACE <br /> I ESTIMATED DATE LAST UYED IMO/Yfl1 - _ <br /> -T--F?-ESTIMATED OUANIIIY F l WAS TANK FILLED WITH <br /> $UGS1ANCE RFMAININ N INERT MATE_ GALLONS YES NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OT PERJURY,A TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT <br /> APPLICANPS NAME IPflINI FR A$11iNA 1 URI I <br /> D/ E!•. <br /> 1 <br /> LOCAL AGENCY USE ONLY <br /> CON E UNTY E JURISDICTION�I N 0 AGENCY A FACILITY ID A <br /> '. TANK 10 I <br /> �_ <br /> CURRENT LOCAL A NCY FAG( TTY 10• _-- <br /> o / <br /> / APPROVED BY NAPE) � PHONE 0 WITH AREA CODE <br /> PERMIT NUMB R I - --- - V� <br /> PERMIT APPROVAL GATE PERMIT EXPIRATION DATE <br /> CNECK• PERNIT AMOUnT SURCHARGE AMT. <br /> FEE CODE RECEIPT EY: <br /> FORM B 19-7.RI1 THIS FORM MUST BEACCOMPANIED BY AFACILITY/SITE APPLICATION, FORMA',UNLESS A CURRENT FORMA' MAS BEEN FILED I <br /> /��D\\ DATA PROCESSING COPY <br />