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1 AIV K I Jany PERMIT APPLICATION INFORM' BION COMPLETE A SEP TE FORM WITH THE FOLLOWING INFORMATI� +OR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ONE ITEM ❑ ❑ ❑ T PE MANENiIY CLOSED TANK T INTERIM PERMIT 4 AMENDED PEflMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED /F FACILITY/SITE NAME WHERE TAN61 K IS INSTALLED; L/ FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK IDM to �' - /7 8. MANUFACTURED BY: C. YEAR INSTALLED w/ D. TANK CAPACITY IN GALLONS: 11. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C-IF(A.1),IS NOT MARKED,CO ETE ITEM 0. A A. I MOTOR VEHICLE FUEL 2PETROLEUM R TV ❑ C UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ /OIL —�],�PR/ODUCT GASAHOL ❑5 HAZARDOUS �+ ❑ ❑5 JET FUEL ❑6 DIESELAVIATION GAS TV ❑BO EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ T METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED A C.A.S.N (CAS.E. .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.8,C.LD A TYPE OF ^❑�1 DOUBLE WAILED E]3 SINGLE WALLED NTH EXTERIOR LINER ❑%UNKgOVM SYSTEM I..f WALLED ❑I SECONDARY CONTAINMENT ❑99 OTHER B. TANK STEELIADN ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑1 STEEL CLAD W/FIBERGLASS RENORCED PLASTIC ❑5 CONCRETE MATERIAL ❑6 POlrvuq'L GILOROF ❑ )ALUMINUM ❑B IDOL MERMAID(COMPATIBE FW ❑9 BRONZE ❑ 10 GALYAMZEDSTEEI ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBERLINE91 ❑ 2 ALKYDLINNG ❑3 EPDXY LING ❑T PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINED i ! S.MEy wwm ❑IS LINING MATERIAL COMPATIBLE WITH IOD%NEfIMNpL'• 0YE5 ❑ NO 099 OTHER rD.CORROSION ❑ 1 POLYETHENE WRAP ❑2 TARORA9BALT ❑ 3 VINYL NMP ❑I FBERGASS REINFORCED PLASTIC TECTION ❑5 CATHODIC PROTECTION ❑91 NONE %KNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ADOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE p A SYSTEM TYPE 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER 1 B. CONSTRUCTION A U SINGLE WALLED _ A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U %IT A U 99 O1HEq U STEEL/IRON A U 2 SIAINLESSSTEEI A U 3 POLYVINYL CHLORIDE IPVCI A U FIBERGLASS PIPE C. MATERIAL A 5 ALUMINUM A U 6 CONCRE IF A U ] STEEL CLAD W/i RP A U B 1906 METHANOL COMPATIBLE FNP A U 9 GALVANUEGSILEL A U 95 UNKNOWN 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 P 5 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P SE WELLS P 5 ELECTRONIC MONITOR ► 5 SGROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 2 PRESSURE TESTING / 5 91 NONE P S 95 UNKNOWN P 5 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1 ESTIMATED DATE LAST USED IMO/MRI ` ESTIMATED QUANTITY OF I WAS TANK FILLED WITH SIBSIANLE REMAINING IN GALLONS INERT MATERIAL' ❑YES ❑ NUj THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT APPLICANTS NAMF IPRINIFO R SGNPIIPII I oA,E!•. 1 I LOCAL AGENCY USE ONLY COU_NNNTT`YYYN JURISDICTION AGENCY# FACILITY TDF � TANK ID K IYFA ILLIJ- -_IL—I�JI - CWRENi LOCAL AGENCY FACILITY IO,I APPROVEOBY%AYEgDAW 7 Q D -� ./5PRONE I WIT%AgEA CODE PERMIT NUMBER Ti PERMIT A ROVAL DATE PERMITB�O"MCNECKE PERMIT AMOUNT SURCHARGE AMT. FEE CODE 9Y: �FOAMB(3.T.IM) THIS FORM MUST BEACCOMPANIED BY AFACILITY/SITE APPLICATION, FORM 'A'.UNLESS A CURRENT FORMA' HASSEENFILED -- _ DATA PROCESSING COPY �C llw . ..... ..dv.:,uSIA+P.Am.IVBSIEYRSI•r ss:..