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I A14K I AN'! PERMIT APPLICATION INFORM `TION Iq COMPLETE A SLS �; (ATE FORM WITH THE FOLLOWING INFORMA—N FOR EACH TANK. i, 'tl�, I MARK ONLY ❑ 1 NEW PERMIT O RENEWAL PERMIT S CHANGE Of INFORMATION ONE ITEM Z PERMANENTLY CLOSED TANK 0 2 INTERIM PERMIT /AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ■R TANK REMOVED FACILITY/BITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES NO _7 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN 80 SPECIFY to A OWNERS TANK IDR B. MANUFACTURED BY: v C. C. YEAR INSTALLED +� v D TANK CA TUBE�ITE GALLONS 11. TANK CONTENTS IF(AI IS MARKED,COMPLETE ITEM C.IF(AI 18 NOT MARKED,COMPLETE ITEM D. ? A ❑ I MOTOR VEHICLE FUEL 2 PETROLEUM B. C. ❑ I UNLEADED 0 2 LEADED O DIESEL `7 O CHEMICAL PRODUCT /OIL N 1 PRODUCT 0/GASANOL E]5 JET FUEL 6 AVIATION GAS cl 5 HAZARDOUS SO EMPTY UNKNOWN 2 WASTE El 2 METHANOL [:]99 OTHER(DESCRIBE W ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL-ENTER NAME OF HAZARDOUS SUBSTANCE STORED S C.A.S.N K v- .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A.B,C.A D A TYPE OF ❑ I DOUBLE WALLED E]O SINGLE WALLED MIN EXTERIOR LINER �•�S IpRNONN SYSTEM 2 SINGLE WALLED 1 SECONDARY CONTAINMENT 99 OTHER B.TANK 1 STEELIRON 2 STAINLESS STEEL 0 O FIBERGLASS 0 1 STEEL CUD WIFIBERGIA$SREN FORCED PLASTIC ,1 E:] 5 CONCRETE;( MATERIAL ❑6 POLYWNYI GRpEOF 1-1 'A UMNUM El B 10011MElIW1OL COMPATIBLE FW 0 9 BRONZE 010 GALVANIZEDSTEH UNKNOWN [D 99 OTHER C. INTERIOR 1:1 1 RIBBERLIED 0 2 ALKYDUNING J EPDXY LINING —]4 PPHENOLIC LINING LINING ID GLASS LINING EI6 UUMD / I fes % WN 0I LINING MATERIAL COMPATIBLE MTN IW►METRAI YES NO ❑u 99 OTHER 0. CORROSION IPOLYETHLEM WRAP El2 TAR OR ASPHALT .-_QVWYL WRAP 1 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE ASYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U ]GRAVRY 99 OTHER B.CONSTRUCTION A U I SINGLE WAUEO A U 2 DOUSLE WALLED A U ]LINED TRENCH U A U "OTHER A U I STEEL/IRON A U 2 $TMNLESSSIFFL A U ] POLYWNYLCIILORIDEIPVC) A U A FIBSS ERGLAPIPE C. MATERIA( A U 5 ALUMINUM A U_yCON A U ) STEEL CLAD W/FNP A U 9 GALVANIZED STEEL A 95 UNIA U S 10016.METHANOL COMPATIBLE FRP A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY.OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. i S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S ]VADOSE WELLS P S A ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S /PRESSURE TESTING -�y1yD� P 8 95 UNKNOWN P S "OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I ESTIMATED DATE LAST USED IMO/MRI 2 ESTIMATED OUANtI1Y OF I SUBSTANCE REMAINING IN ] WAS TANK FILLED` ATH GALLONS INERT MATERIALS YE$ NG� THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME IPRINIFD A SIGNa RI1il 1 � LOCALAGENCYUSE ONLY • C07–� JURISDICTION �� AGENCY P FACILITY ID N TANK ID P _ UDz �,. .00o 3 CURRENT LOCAL AGENCY FACILITY NIP - APPROVED BY NAME PHONE E WITH AREA CODE PERMIT NUMBEq PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK• PERMIT AMOUNT SURCHARGE AMT. FEE CODE gECE1PT F BY. FORM Bpa-NMI THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SRE APPLICATION, FORM W,UNLESS A CURRENT FORMA' HAS BEENF D ---- -- - - DATA PROCESSING COPY Z�u:;;v:,"wT8'L.-Mm^'.L'd++; KBIq�1Err'1w:.>.-s_,� .....:w.,. , ,:,,_... ._..::..,.._.....—_..__..