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I Ar4K IJ%NK PERMIT APPLICATION INFORMATION �, <br /> COMPLETE A SEP ITE FORM WITH THE FOLLOWING INFORMATL�fOR EACH TANK. id,P ' <br /> MARK ONLY ❑ I NEW PERMIT ❑9 RENEWALPERMIT 121 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM ❑ 2 INTERIM PERMIT 6 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE B TANK REMOVED <br /> FACILITY/BITE NAME WHERE TANK IS INSTALLED; (p _ If�O (� FARM TANK-YES❑ NO <br /> _7 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY to <br /> A OWNERS TANK IDN V. It. B. MANUFACTURED BY: ` - <br /> LC. YEAR INSTALLED V_k I D TANK CAPACITY IN GALLONS: 4%o <br /> II. TANK CONTENTS IF(A1),18 MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. A <br /> N <br /> A ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ I UNLEADED ❑2 LEADED El 7 DIESEL <br /> ❑7 CHEMICAL PRODUCT ©j pIL ❑ 1 PRODUCT ❑/GASAHOL ❑5 FUEL ❑6 AVIATION GAS N <br /> ❑5 HAZARDOUS ❑80 EMPTY [j 95 UNKNOWN 1 WASTE ❑ 1 METHANOL 99 OTHER(DESCRIBE IN ITEM 0.BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED A C.A.S.N ulg O. CAS.N. <br /> KIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A.S.C,i D <br /> A TYPE OF WALLED 75OLE WALLED WITH EXTERIOR LE <br /> SYSTEM ❑ E 95UBNOM <br /> 2 SIHGIF WALLED ❑/SECOMBANCOITN IMENT ❑99 OTHER <br /> B.TANK I STEEUIRON E]2 STNNLESSSTEEL 7 FIBERGLASS ❑1 STEEL CLAD WIFBERGIASSRENfORCED ELASTIC <br /> ;( MATERIAL ❑S CONCRETE ❑6 POLYVINYL OILORU ❑ 7 ALUMINUM ❑8 180%METHANOL COMPATIBLE FRP <br /> ❑9 BRONZE 18 GALVANIZED STEN ❑95 UNKNOWN ❑99 OTHER <br /> C. INTERIOR ❑ 1 RLBBERLINED ❑2 ALKYOUNING ❑ 7 EPDXY LINING O,4VMENOLIC UMNG <br /> LINING ❑5 GLAm DUAL ❑6 MINED I I 25 UNKNOWN <br /> ❑ISLINING MATERIAL COMPATIBLE WITH IW%METIMNOLT ❑YES ❑ NO ❑UUU❑M OTHER <br /> D.CORROSION ❑ 1 POYEREENEWRAP ❑2TAR OR ASPHALT ❑ (WRAP ❑1 FIBERGLASS REINFORCED KWIC <br /> PROTECTION El CATHOUC PROTECTION 1:191 NONE <br /> 95 UNKNOWN ❑99 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 7 GRAVITY <br /> A U "OTHER <br /> B,CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 7 LVED TRENCH A <br /> UNKNOWN A U "OTHER <br /> A 101 STEEL/IRON A U 2 STAINLESS SIM A U 7 POLYVINYL CHLORIDE(PVC) A U A FIBERGLASS PIPE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD VV/FRP <br /> A U 9 GALVANIZEDSTLEL A U 95 UNKNOWN A U 99 OTHER A U BIWW METHANOL COMPATIBLE FNP <br /> V. LEAK DETECTION SYSTEM CIRCLE P FORPRIMARy,OR $ FOR SECONDARY.APRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P 5 1 VISUAL CHECK P 2 2 INVENTORY REGONCILIA110N P S ]VADOSE WELLSP S A ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P 5 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE OS 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> I ESOMATED DATE LwST USED IMO/MRI 2 ESTIMATED QUAN717V OF - <br /> WASLYNKf."L ,WITH <br /> Ej <br /> SIIBSI ANCE REMAINING IN INERT MATERIAL'S ❑YE$ NO� <br /> GALLONS J <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 IPRINI Fp A SI GNA t LORI I <br /> 1 J <br /> LOCAL AGENCY USE ONLY <br /> COUNTY A JURISDICTION E AGENCY A FACILITY ID N <br /> � TANK ID N <br /> CU..ENT LOCK AOEHCY FACILITY IDE APPROVED BY NAME <br /> gyp(`m (T PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE -- <br /> PERMIT EXPIRATION DATE <br /> / <br /> CHECK• PERMIT AMOUNT SURCHARGE AMT. 4( -- <br /> FEE CODE RECEIPT N <br /> FORMB17.7.BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HASBEENFILED I <br /> DATA PROCESSING COPY <br />