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TANK TAN 'ERMIT APPLICATION INFORM,,.fION y- <br /> I COMPLETE A SEP)tAATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY ❑ 1 NEW PERMIT S RENEWAL PERMIT 5 CHANGE OF INFORMATION +' <br /> ONE ITEM 2 INTERIM PERMIT 1 PERMANENTLY CLOSED TANK <br /> ❑ 1 AMENDED PERMIT <br /> 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> FACILITY/BITE NAME WHERE TANK IS INSTALLED: n <br /> FARM TANK-YES NO <br /> L TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—So SPECIFY <br /> A 10 <br /> OWNERS TANK 10 E _ <br /> B. MANUFACTURED BY: K <br /> C. YEAR INSTALLED <br /> D. TANK CAPACITY IN GALLONS: <br /> IL TANK NTENTS IF(Al),IS MARKED,COMPLETE ITEM C.IF(A./),IS NOT MARKED,COMPLETE ITEM D. A <br /> A. I MOTOR VEHICLE FUEL 0 2 PETROLEUM 600 <br /> N <br /> f—1C _j 1 UNLEADED �2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT Ej 1 qt �pgOpUCT 1 GASAHOL El 5 JET FUEL 1:1 6 AVIATION GAS N <br /> Cl 5 HAZARDOUS L.EN80 EMPTY E]95 UNKNOWN O 2 WASTE 0 7 METHANOL Ej 99 OTHER(DESCRIBE IN ITEM D.BELOW) <br /> D. IF NOT MOTOR VEHICLE FUETER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C A.S.M <br /> CAS N <br /> .111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A.B,C,&D <br /> A TYPE OF ❑ I DOUBLE WALLED E]3 SINGLE WALLED WITH E%TERIORuWR 95 UNKNOWN <br /> SYSTEM El 2 SINGLE WALLED ❑/SECONDARY CONTAINMENT <br /> 99 OTHER <br /> I STEEURON 02 STAINLESS STEEL 3 FIBERGLASS <br /> B.TANK 5 CONCRETE <br /> 1 STEEL CLAD W/fIBERGIA,S$REBFORCfOPUSTN: <br /> MATERIAL ❑6 POLYVINYLCHLORIDE 0 7 ALU NUM 0 810016METHANOLODWATIBLEFRP <br /> 9 BRONZE 10 GALVANIZED STEEI a UNKNOWN 99 OTHER <br /> C.INTERIOR I RIBBER LINED 2 ALKYD LINING I ❑3 EPDXY LINING� 1p/IL�Nry• ICUMNG <br /> LINING ❑ 5 GLASS LINING 6 UNLINED I I � <br /> g4bWN <br /> ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL' EIYES ONO lift❑9999 OTHER <br /> D. CORROSION ❑ 1 POLYETKEWwRAp E]2 TARORASPHALT ❑ 3 W LWRAP 1 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 0 5 CATHODIC PROTECTION 0 91 NONE 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 U 3 GRAVITY <br /> A U 99 OTHER <br /> B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A68)5,5 UNKNOWN A U MOTHER <br /> A U I STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U d FIBERGLASS PIPE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETF A U 7 STEEL CLAD W/FRP <br /> A U 9 GALVANIZED STEEL A U 5UNKNOWN A U 99OTHER <br /> A U 610pw METHANOL COMPATIBLE FRP <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 5 2 INVENTORY RECONCILIATION P S 3 VADOSE WENS PS d ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> 91 NONE <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING ecz� P S 95 UNKNOWN P S %OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> I. ESTIMATED OATE LAST USED IM01YRI 2 ESTIMATED QUANTITY OF <br /> /�- J. WAS TANK EWITH <br /> VY — <br /> SUBSTANCE REMAINING IX INERT MATERIAL'RIALT YES DND <br /> LY`• GALLONS <br /> THIS FORJ HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT <br /> APPLICANTS NAME IPRINTFO A 511NA 111Rf <br /> DAY <br /> E� <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY R FACILITY ID S TANK ID N <br /> ao131 0 � <br /> CURRENT LOQ I,I. ENCY FACILITY 10• APPROV D eY NAME PHONE 0 WITH AREA CODE <br /> ___ 2 <br /> PERMIT NUMBER PERMITAPPAOVALDA PERMIT EKPIR TI DATE --- <br /> CHECK• PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECENITI BY. <br /> FORM B tYT-8B1 THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS ACURRENT FORMA' NAS BEEN FILED <br /> _ DATA PROCESSING COPY <br />