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I AIV K I AMK PERMIT APPLICATION INFORP"TION <br /> COMPLETE A SE TATE FORM WITH THE FOLLOW( G INFORMANftoN FOR EACH TANK.o • <br /> MARK ONLY I NEW PERMIT 7 RENEWAL PERMIT SCHANGE OF INFORMATIONONE ITEM Ely PERMANENTLY CLO TANK <br /> Ej 2INTERIM PERMIT ED 1 AMENDEOPERMIT 6 TEMPORARY TAM(CLOSURE �B TANK REMOVED <br /> FACILITYYSITE NAME WHERE TANK IS INSTALLED: <br /> AA f+ <br /> 1(7"» FARN TANK-YES NO <br /> I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY <br /> A OWNERS TANK 10 E t' to <br /> B. MANUFACTURED BY: <br /> C. YEAR INSTALLED <br /> 0. TANK CAPAGIY IN GALLONS: <br /> II. TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM A <br /> A. MOTOR VEHICLE FUEL [:D 2 PETROLEUM 9. N <br /> O ❑ I UNLEADED 2 LEADED �7 DIESEL <br /> 7 CHEMICAL PRODUCT E]1 OIL LFI�I'�gI/I PRODUCT A GASAHOL 5 JET FUEL 6 AVIATION GAS N <br /> S HAZARDOUS ❑ 1p EMPTY �95 UNKNOWN LJ 2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D.BELOW( <br /> D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED A C A .N <br /> CA S.e. <br /> ,III. TANK CONSTRUCTION MARKONEITEMONLYINBOXA,B,C,AD <br /> A TYPE OF ❑ 1 DOUBLE WALLED Ej 3 SINGLE WALLED WITH[)[TENOR LINER E]95 UNKNOWN <br /> SYSTEM 2SNGLE WALLED 1 SECONDMYCONTMNMENT 99 OTHER <br /> 1 STEEUIFON 2 STAINLESS STEEL 7 FIBERGLASS 1 STEEL CLAD W/FIBERGLASS REBfORLAS <br /> CFD PTIC <br /> S YAITERIAL ❑ 5 CONCRETE6 POLYVINYL CHLOROF 1 ALUMNUII B IW%METHANOL COMPATIBLE FRP <br /> 9 BRONZE 0 IB GALVANIZED STELA 95 UNKNOWN 99 OTHER <br /> C. INTERIOR ❑ I RIBBERUNED E)2 ALKYD LINING 0 3 EPDXY LINING 1 PHENOLICUNING <br /> LINING ❑ 5 GLASSLWING 0 6 UNLINED I I F-I 95 LMNOWN <br /> Cl IS LINING MATERIAL COMPATIBLE WITH IOD%METHANOL, 0 YES [—] NO E]99 OTHER <br /> D.CORROSION ❑ 1 POLYETNIFNEWRAP 2 TAR OR ASPHALT 3 WNYL MMP E]1 FBERGLASS REINFORCED PIA$TC <br /> PROTECTION 5 CATHODIC PROTECTION E]91 NOF E 095 UNKNOWN 1:199 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A SYSTEM TYPE A U I 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 A U 95 UNKNOWN A U 99 OTHER <br /> A U I STEEL/IRON A U 2 STAINLESSSTIEI A U 3 POLYVINYL CHLORIDE(PVC) A U I FIBERGLASSPIPE <br /> C. MATERIAL A U $ALUMINUM A U 6 CGNCRETf A U I STEEL CLAD W/FOP <br /> A U B11K1%METHANOL COMPAIIpLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 DIMER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> i <br /> P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 5 A ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S I PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN <br /> S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1 ESTIMATED DATE LAST USED IMO/YR1 ESLMAIEDOUANTITYOF <br /> 1 WASTANKF,ILLEDMTH <br /> St1pS1ANCE REMAINING IN INERT MATERIALY YES �No <br /> _ GALLONS J <br /> THIS FORM HAS BEEN COMPLETED UNDER PENAL TY OF/'EHJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRIMED 6 SIGNA I LME DIt E <br /> 1 J :I <br /> LOCAL AGENCY USE ONLY n <br /> COUNTY F JURISDICTION F AGENCY A <br /> TANK ID F <br /> 4 3 3 <br /> CURRENT LOCAL AGENCY FACILITY 10 F APPROVED <br /> PHONE F WITH AREA CODE <br /> PER RMIT APPROVAL DATE PERMIT EK%gAT10M DATE <br /> CHECK• PERMIT AMOUNT SURCHARGE AMT. Wr <br /> FEE CODE gECEI/T F <br /> FORM 8137-BBI THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A•,UNLESS A CURRENT FORM'A' HAS BEEN FILED <br /> DATA PROCESSING COPY <br /> a1tlri.Tw'S"AT?e::RtK..•L'c7'. <br />