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I HIV K l hnK PtftMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK, <br /> MARK ONLY p 1 NEWPERMITn <br /> ONE ITEM ❑0 RENEWAL PERMIT �5 CHANGE OF INFORMATION <br /> 2 INTERIM PERMIT 1 AMENDED PERMITp T PERMANENTLY CLOSED TANK <br /> 11 <br /> FACILITYASITE NAME WHERE TANK 181NSTALLEQ ❑fi TEMPORARY TANK CLOSURE ANK REMOVED G <br /> L TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN�gO SPECIFY FARMTANK-YESEj NO <br /> A OWNERS TANK ID N <br /> f O <br /> C. YEAR INSTALLED B. MANUFACTURED BY: - <br /> D. TANK CAPAGTY IN GALLONS: <br /> II. TANK 4TENTS IF(A.1).IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,C PLETE ITEM O. <br /> A. I MOTOR VEHICLE FUEL A <br /> t PETROLEUM q N <br /> 0 0 CHEMICAL PRODUCT 1 OIL e" C ❑1��UNLEADED ❑5 LEADED D E]7 DIESEL N <br /> 5 HAZARDOUS E3 I PRODUCTEl BO EMPTY EJ95 UNKNOWN 2 WASTE T METHANOL 99 OTHER(DESCRIBE IN TEND AVIATION <br /> OEN GA <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED 6 C.A.S.N <br /> x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B.C,i 0 C.A.S.N <br /> A. TYPE OF ❑ I DOUBLE WALLED Lj]SINGLE WALLED MTN EXIER IR LNER <br /> SYSTEM 2 SINGLE WALLED A UNKWN <br /> SECONDARY CONTNNMENT ❑% � <br /> H OTHER <br /> a B. TANK ❑ 1 STEEL/IRON 2 STAINLESS STEEL Lj 7 FIBERGLASS Ej 1 STEEL CIAO W/FIKWAASSRENFOFICED MASTIC <br /> MATERIAL E] 5 CONCRETE fi POLYVINYL ORDAIN 1 ALUMINUM O B 100%METHMNpL COMPATIBLE FRP <br /> 9&ONZE 0 B GALVANIZEDSTEEI %UNKNOWN 99 OTHER <br /> C. <br /> I R88ERLIWO 2 KYDLNING -" 7 EPDXYLIMNG <br /> INTERIOR LINING <br /> 5 GLASS LINING a n fi RED , ❑1 PHENOLIC LINING <br /> ❑%UNKNOWN <br /> S LINING MATERIAL COMPATIBLE MINI HWgLi O YES [ NO 990MER <br /> O.CORROSION ❑ i POLYETHUNE WRAP 2 TABOR T 0 J VINYL WRAP <br /> PROTECTION 1 FIBERGLASS REINFORCED PLASTIC <br /> S Gi1gpN;PROTECTIONEj 91 NONE %UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GR NU. U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A SYSTEM TYPE A U I SUCTION A U 2 PRE E <br /> A U 9 GRAVITY A U 99 OTHER <br /> B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE LLED A U 9 LINED TRENCH A U 95 UNKNOWN <br /> A U I STEEL/IRON A A U "OTHER <br /> C. MATERIAL U J STAINLESS. EEI A U ]POLYVINYL CHLORIDE IPVCI A U K FIBERGLASSPIPE <br /> A U $ ALUMINUM A U 6 CONCRETE A U I STEEL CLAD W/FIN <br /> A U AIOBN METHANOL COMPATIBLE FNP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN <br /> A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FORPRIMARY.OR S OR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> i <br /> P S I VISUAL CHECK P S 2 INVENipgY RECONCILIATION P S 9 VAOD WELLS P S 4 ELECTRONIC MONITOR P g 5 GROUND WATER MONITORING WELLS <br /> S I PRESSURE IEST <br /> P g 6 PRECISION TESTING P ING P S 91 NONE P S 95 UNKNOWN <br /> P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN ACE <br /> I fSTIMATE00ATE LAST USED IMO/YNI --_- <br /> ' ESTIMATED QUANTITY OR T Wq$1ANK FILLED WITH <br /> SUBSTANCE REMAINING IN INERT MATERIAL' <br /> - __ GALLONS E]YES 0 NU <br /> THIS FORM HAS BE COMPLETED UNDER PENAL TY 01- PERJURY.AND THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT <br /> APPLICANT'SNAME IPHINTFDXS., 1UHF1 <br /> o�E!•. <br /> 1 I <br /> LOCAL AGENCY USE ONLY <br /> COUNTY K JURISDICTION N AGENCY N FACILITY 10 N <br /> TAN <br /> •.D � K I`J / <br /> CURRENT L L AGENC ACILITr ID E <br /> APPROVED BY NAY( � ^� pyo PHONE/WITH AREA CODE <br /> PERMIT NUNMR - - PERMIT APPROVAL DATE Y „` <br /> PERMIT EENRATION GATE <br /> CHECK F PERMIT AMOUNT SURCHARGE ANY. <br /> FEE CODE RECEIPT E <br /> 1r: <br /> FDRMBIa 2ae1 THIS FORM MUST BE ACCOMPANIED BYAFACKITYYSITE APPLICATION, FORMA*,UNLESS A CURRENT FORMA' HAS BEEN FILED <br />-----.-___ _ DATA PROCESSING COPY <br />