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MASTEH FILE HECORO INFORMATION FOHM <br /> S tJ ° - - _ <br /> Ac1,e11 c, mIy rogl' ub El e Co.Neww t+o• " (9•,Iv <br /> (71 <br /> E .H . � _ (assigned by clerk) <br /> P/S . E . Local Como . Number Sun/Dist . location CodeFee Ex <br /> FR- E � r JQ o T , l E <br /> Preyious Comp. Numcen Effective oat* Other Program Activity <br /> i L <br /> SITE NAME (30 ctwacto(s) <br /> SITEAddress (no:/Dir/Street/Suffix/Suite) Site City/State/Zi <br /> C /9 <br /> /0H ACRD 0"T7 61D L <br /> PRE410US DDA <br /> B i 11 i ra i7ame <br /> Billing Address (No/Dir/Street/Suffix/Suite) Billina' City/State/Zip <br /> 049 0-x ?7 / 17 <br /> 6,00 7,2> /000-To--;,� <br /> EST yZE JTE TELENIC4.,E MA40ZR <br /> SOD < X000 / seats <br /> Sq � I I I I <br /> I I <br /> � I--. Ft. <br /> / Un l Its <br /> L_1_L!I <br /> avNEn`LM4E (JO Ctu ZCW3) . <br /> OWNER „ddress ((JD ./Oir/Street/Suffix/Suite) (Omer City/State/Zip <br /> SPEC IAL PROGRAM rRFORtIATION No, of S*Nlei Source of Tieument Population <br /> . Conncellont Supply TYN Carved <br /> Rec. Health 4later ❑ 1 m LLLI <br /> ADD! 71ONAL COtINIENTIS : <br /> san. sL,� nc sr, <br /> EH 01 15 I( 1� <br /> u ...••..•... U ��unwnniteU5R5L L 95 UNKNOWN U 99 OTHER <br /> C.INTERIOR F-] 1 RUBBER LINED ❑2 ALKYD LINING W3 EPDXY LINING E] 4 PHENOLIC LINING <br /> LINING ❑5 GLASS LINING ❑6 UNLINED [At KN ❑ 95 UNKNOWN r/ <br /> ❑ IS LINING MATERIAL COMPATIBLE WITH 1 w%METHANOL?/❑ YES ❑ NO 99 OTHER GI hK <br /> D.CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER UK 0 <br /> IV. PIPING INFORMATION CIRCLE IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A &A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE <br /> C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL 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 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 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 8 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> i. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E]GALLONS <br /> E:] NO <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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION# AGENCY N - FACILITY ID* TANK ID R <br /> 6 6 0 In I 1 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE#WITH AREA CODE <br /> ^u ' e <br /> PERMIT NUMBER PERMIT APPROVAL DATE PI ITEXPIRATION DATE <br /> CHECK# PERMIT AMOUNT I SURCHARGEAMT. FEE CODE RECEIPT# BY: <br /> FORM B(6-29-89) THIS FORM MUST BE ACCOMPANI A FwLRY/SITE APPLICATION, FORM 'A',UNLESS kw*NRENT FORM'R HAS BEEN FILED <br /> DATA PROCESSING COPY <br />