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I ANK IAIVK PERMIT APPLICATION INFORMPtION COMPLETE A SEP, TE FORM WITH THE FOLLOWIN INFORMATI fOq EACH TANK- QFACILM/$lT;EN;AM;EWH;ERE EW PERMIT ❑D RENEWAL PERMIT 5 CHANGE OF INFORMATION TERIM PERMIT ❑ I PERMANENTLY CLOSED TANK ❑A AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED O TANK IS INSTALLED: - _ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY / FARM TANK-YES NO A OWNERS TANK IDB I o B. MANUFACTURED ETY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: C- II. TANK ONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. A A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM f V ❑ D CHEMICAL PRODUCT ❑A OIL FBS E C' ❑ I UNLEADED ❑2 LEADED O DIESEL N IGJ ' MKT ❑A MTHHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ S HAZARDOUS ❑ BD EMPry ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) D. If NOT MOTOR VEHICLE fUEL ENTER NAME OF HAZARDOUS SUBSTANCE STORED S C A.S.B GAS.B. Alll. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B.C,A D A.TYPE OF ❑ 1 DOIMLF WALLED ❑7 SINGLE WALLED WITH EXTERIOR LINF n SYSTEM ❑ EDU 95 KNOWN 2 SINGLE WALLED ❑A SECONDARY CONTAINMENT ❑99 OTHER { S TANK ❑ 5 STEEL/BpryE ❑2 STNNf55 STEEL ❑7 FIBERGLASS E]I STEEL CLIOW/FBERGLLSSROMFORCEDRASTC ❑6 POLYVINYL CHLOROF ❑ 7 ALUMINUM ❑B IBD%METHANOL COMPATIBLE RP ❑9 BRONZE ED10 GALVANIZED STELE El 95 UNKNOWN 99 OTHER C.INTERIOR ❑ I RIBBER LINED ❑2 ALI(YO UNNIG E]7 EPDXY LINING ❑1 PHENOLCUMNG LINING ❑5 CAASSLNNG ❑6 UNLINED I I ❑IS UNKNOWN ❑IS LINING MATERIAL COMPATELE WITH 100%METHANOL, ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYETHAENE WIMP ❑2 TARORASPHALT .__.❑7 VWYL WRAP ❑1 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION91 NOEL( ❑ ❑95 UNKNOWN ❑W 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 J GRAVITY A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 9 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STARILESSSTEEI A U 9 POLYVINYL CHLORIDE IPVCI A U I FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRE/F A U ! STEEL CLAD W/FNP A U 9 GALVANIZEOSTLEL A U 95 UNKNOWN A U 99 OTHER A U BIBB%METHANOL COMPATIBLE NTP 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 ]VADOSE WELLS P S A ELECTRONIC MONITOR P S 5 GROUND WATERMONIRMING WELLS P S 6 PRECISION TESTING P $ 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S "OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I ESTIMATED DATE)AST USED IMO/YRI 2 ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN WAS I MIK EILLED WITH -- __ GALLONS INERT MATERIAL' ❑ YES E]N0� THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT S NAMF(PINNI FD A SIGNA I EpB DES E!•. LOCAL AGENCY USE ONLY B COUNTY B JURISDICTION B AGENCY F IUTY ID B TANK ID B CURRENT LOCAL AGENCT FACILITY ID F APPROVED BY NAME PHONE 1 WITH AREA CODE PERMIT NUMBER - --- PERMIT APPROVAL DATE PERMIT EBNRATION DATE CHECK• PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT• B FORMBI7 T-0BI THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM'A' HASSEENFR,ED I DATA PROCESSING COPY a�1tYl:wti19iX6Y i't'N.'.:+�iCIiIARZLIVM'uRRR4' i 'i..e-.:x1:, ;.:,u.•V > ..ssv.0 -