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AN K I ANK PERMIT APPLICATION INFORV 1TION / {� COMPLETEASk TATE FORM WITH THE FOLLOWING INFORMA,�N FOR EACH TANK..,,,_,'.J MARK ONLY ❑ 1 NEWPERMIT 0 O RENEWAL PERMIT 5 CHANGE OF INFORMATION ONE ITEM / PERMANENTLY CLOSED TANK . E]21NTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: //6 11 , G FAgN TANK-YES❑ NO ❑ L TANK DESCRIPTION COMPLETE ALL ITEMS-IFUNKNOWN- SO SPECIFY ! O A OWNERS TANK 10 N B. MANUFACTURED BY: U �, C.YEAR INSTALLED 61. K D. TANK CAPACITY IN GALLONS: /)�� II. TANK CONTENTS IF(Al),IS MARKED,COMPLETE ITEM C.IF(Al),IS NOT MARKED,COMPLETE ITEM D. L A A ❑ I MOTOR VEHICLE FUEL ❑2 PETROLEUM N ❑7 CHEMICAL PRODUCT ❑ 1 OIL B C' ❑ 1 UNLEADED ❑2 LEADED ❑7 DIESEL N ET FUEL ❑S HAZARDOUS ❑BO ION GAS EMPTY 95 UNKNOWN ❑2 WAPRODUCT ❑ 7 METHANOL ❑99JOTHER(DESCRIa TEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C A.S.N C.A.S.N: UOL, AIII- TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A.B,C.i D A.TYPE OF ❑ I ODLIBEWAILED ❑7 SINGLE WALLEDWIIHEKTERIORUNER %LINK YINSYSTEM ❑2 SNRIE WAMED ❑1 SECONOA W CONTAINMENT W OTTER B.TANK ❑ I STEEL/ERN ❑2 STAINLESS STEEL ❑7 FSERGLAM ❑A STEEL CLAD W/FBERGLASSREKDAGED PLISIK MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYL CHLORK* ❑ 7 ALUWNUMcl ❑B 100%METHANOL COMPATIBLE FRP 9 BRONZE ❑ 10 GALVANIZED STEER Er,95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR 1 KSKRLNIEO 2 ALKMLNING -.. ❑9 EPDXY LINING ❑1 NOLICUMNG ❑ LINING ❑5 GLASS LINING ❑6 LNIUNED I I � gs:NOxM ❑IS LNVG MATERIAL COMPATIBLE MTN 101%uETHANOLT ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYETHENE WRAP ❑2 TAR OR ASRMLT NVI WRAP ❑1 FSEAGLASS REINFORCED PLASTIC PROTECTION [115 C•ATHOOC PROTECTION ❑ 91 NONE w99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND.BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U ]GRAVITY 99 8. CONSTRUCTION A U I SINGLE OTHER WALLED A U 2 OOUBLE WALLED A U D LINED TRENCH A U I STEELPROn A U 99 OTHER A U 2$RAINLESS STEFI A U ]POLYVINYL CHLORIDE(PVC) A U KfIBERGLASS PIPE C. MATERIAL A u 5 ALUMINUM A U 6 CONCRETE A U I STEEL CLAD W/FNP A U B IOD%METHANOL COMPAI ISLE FRP A U 9 GALVANIZEDSIIEt 9_�- —. A U 99 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 2INVENTORY RECONCILIATION P S 9 VADOSE WELLS P S A ELECTRONIC MONITOR P S 6 PRECISION TESTING P S I PRESSURE TESTING P S 91 P S $GROUND WATER MONITORING WELLS P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I ESTIMATED DATE LAST USED IMO/YRI ? ESuunifO QUANTITY Of 9UBSIANCEREMAMINGIN WASTMJKFILLED — — GALLONS INERT MATENµ WITH' 0 YES 0 NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND COflRECT APPLICANT'S NAME IPgINifO A$IGNAIIIIII I oq E!•. LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N �_ _ FACILITY LIT�N -I ••� OINK ID E CURRENT LOCAL AGENCY FACILITY ION - O O L APPROVED EY NAME PHONE N WITH AREA CODE PERMIT NUMBER — -- PERMITAPMROVALO.ATE PERMIT EERRATION DATE CHECK F PERMIT AMOUNT SURCHARGE AWT. FEE CODE RECEIPT N er: � f011MB192-E81 THIS FORM MUST BE ACCOYPANIEDBYAFACILITY/SITEAPPLICATION, FORM -A',UNLESSACURRENT FORY'A' HAS BEEN FILED /, I ---- - _ DATA PROCESSING COPY eTal..^m�'SCB:waIN,� :9JNp�ASCmE.aErfTDrs.'Li:i: ,>xx-