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ANK IANK PERMIT APPLICATION INFORP' TION COMPLETE A S LATE FORM WITH THE FOLLOWING INFORMA�4 FOR EACH TANK }.�;�°.�,.� MARK ONLY ❑ I NEWPERMIT ❑O RENEWAL PERMIT SCHANGEOF INFORMATION ONE ITEM 2 INTERIM PERMITEl ❑ 1 PERMANENTLY CLOSED TANK A PI DPERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: p K�I I. TANK DESCRIPTION COMPLETE ALL ITEMS; WIKNOWN—SO SPECIFY FARM TANK•YES❑ NO ❑ AOWNERS TANKIDN 6 1 O B. MANUFACTURED BY: U- C.YEAR INSTALLED (/.K• D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.11,IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. A A' ❑ I MOTOR VEHICLE FUEL ❑[OOEMPI'l TROLEUM N B' C. ❑ 1 UNLEADED ❑2 LEADED ❑J DIESEL N O CHEMICAL PRODUCT � ❑ I PRODUCT ❑A GASAHOL ❑5 Al FUEL ❑6 AVIATION GAS ❑5.HAZARDOUS ❑ 1"�!:UINXM)WN ❑ 2 WASTE ❑ /METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW( D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 C A.S.9 V.K. C.A.&E: Kill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BO%A,B,C,6 D �' K A TYPE OF ❑ I DOUBLE WALLED ❑3SINGLEWALLED WITH EXTERIOR UNER EtlySLANNaWT1 SYSTEM 2 SINGLE WALLED A SECONDARYCONT"WENT 99 OTHER i L TANK ❑ 1 STEELIRON ❑2 STAINLESS SfEB 7 F18ERGLASS F STEEL CLAD W/FBEIGIASS REEIWR((tp KWICI MATERIAL [—]5 CONCRETE ❑6 POLYVINYLCHDROF ❑ /ALUMINUM ❑6'on METIMNOLCOMPAIIBIEFRP E] 9 BRONZE ❑ 10 GALVANIZED SRfI B�95 UNKNOWN ❑99 OTHER ❑ VfD UNWG ..... 1EPDXY MING C.INTERIOR I RUBBERL2ALMID ❑ ❑T PHENOLIC LENTIG LINING ❑5 GIASS LWYIG ❑6 UNLINED I 1 ClISLQ%UNKNOWN MNG MATERIAL COMPATIBLE IOOII UETHANO, YES [:1 NO ❑95 OTHER D.CORROSION ❑ I POLYETLLENE WRAP' ❑2 TAR OR ASPHALT ❑'�2 VINYL WRAP ❑F RBERGLASSREINFORCEDPLASTC PROTECTION [—] 5 GTHOOICPAOTECTKNI E]91 NONE l Kn UNKNOWN ❑IS OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND.BOTH IF APPLICABLE FASYSTEM TYPE !AU I SUCTION A u g PRESSURE STRUCTION l SINGLE wALLEo A u g g GRAVITY A DOUBLE WALLED A U 9 LINED TRENCH - 95 UNK1 STEEL/IRON A U 99 OTHERERIAL A U 2 STAINLESSSTEFI A U 9 POLYWNYLCHLORIDEIPvC) A K A FIBERGLASS PIPE 5 ALUMINUM A U 6 CONCRETE A U ! STEEL CLAD W/FNP 9GALVANIIEp SIS A U BIWWMETHANOL COMPATIBLE THP ANUWIT� 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 9 VADOSE WELLS F S A ELECTRONIC MONITOR P S 5 GROUND WATERMONITORING WELLS P S 6 PRECISION TESTING P S 2 PRESSURE TESTING 91 NON P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I ESTIMATED GATE LAST USED IMO/YRI - T2 SlIBSTESTIMNC QUANTITYOF1 SUdS1ANCE REMAINING IN ] WAS TANK FALL EO WITH GALLONS INERT MATERIAL+ YES NU� THIS FORM HAS BEEN COMPLETED UNDER PENAL N OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME IPRINI FO A SI(:NA I UR1 I O1 o•. I 1' LOCAL AGENCY USE ONLY B COUNTY E JURISDICTION E ATGENCY I v D FACILITY IDE ..D TANK 10 0 CURRENT LOCAL AGENCY FACILITY 10• ��_ -- _.. JJ (/ APPROVED BY NAME ►HONE K WITH AREA CODE PERMIT NUMBER -'--'— EH"GE RMITAPPROVALOATE PERMIT EKNRATION DATE CHECK K PERI MIT AMOUNT SURANY. FEE CODE RECEIPT Br: — FORM BI9/ I THIS FORM MUST BE ACCOMPANIED BTAFACILTTY/SITE APPLICATION, FO R M 'A',UNLESS A CURRENT FORM'A' HAS BEEN FILED ' ' BB _. ....... . DATA PROCESSING COPY