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TANK � TANK PERMIT APPLICATION INFORMATION (/ COMPLETE A SEPARATE FORM WITH THE FOLLO r INGVWORMATION FOR EACH TANK. .+ , MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL NK ONE ITEM 2 INTERIM PERMIT A AMENDEDPERMIT 6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: D D Id. kNK-YES❑ NO -7 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY to A. OWNERS TANK IDM B. MANUFACTURED BY: C. YEAR INSTALLED - D. TANK CAPACITY IN GALLONS: A II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. f V A. ❑ I MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑1 OIL ❑ I PRODUCT ❑A GASAHOL ❑5 JET KIEL ❑ 6 AVIATION GAS N ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) O. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED A C.A.S.R C A.S.P. KIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A.8,C.A D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑A SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEELIRON E:]2 STAINLESS STEEL ❑3 FBER AASS ❑1 STEEL CURGL D W/FIBEASS REWORDED ELASTICB.TANK MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYL OLOROF F-1T ALUMINUM ❑6100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 BIWA C. INTERIOR ❑ I RUBBERLWED ❑2 ALKYD UMNG ❑ 3 EPDXY LINING ❑/PHENOICUMNG I LINING ❑5 GLASS LING ❑6 UNLINED I El 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 1011%METHANOL' ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ I POLYETHENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHOOIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND.BOTH IF APPLICABLE y A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER 1 B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U W OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLY NYL CHLORIDE(PVC( A U A FIBERGLASS PIPE C. MATERIAL A U 5ALUMINUM A U 6CONCRETE A U 7STEEL CLAD W/FRP A U 6100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U "OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY.OR S FOR SECONDARY.A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 3 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE LAST USED(MONET 2 ESTIMATED OUANTITY OF T WAS TANK FILLED WITH SUBSTANCE REMAINING INGALLONS INERT MATERIAL° ❑YES [:] ND ��JJ-_—_ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) DIT ITI. J LOCAL AGENCY USE ONLY COUNTY P JURISDICTION R AGENCY P FACILITY ID P TANK IO P C�7 � � s fav CURRENT LOCAL AGENCY FACILITY ID F APPROVED BY NAME PHONE E WITH AREA CODE &topw- 16 PERMIT NUMBER PERMIT wPPROVAI DATE PERMIT"PIRAMN DATE ��O CHECK/ PERMIT wMOUNT SURCHARGE AMT. FEE CODE RECEEPT I BY. FORM0437BB) THIS FORM MUST BE ACCOMPANIED BYAFACIUTYISITEAPPLICATIOK FORM W.UNLESS A CURRENT FORMA HASBEENFI/L/LE�D/, r DATA PROCESSING COPY 'wow