BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

TANK TANERMIT APPLICATION INFORM[ .ON' �T'271 COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMAT1 FR EACH TANK.MARK ONLY ❑ 1 NEWPERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ONE ITEM ❑ 7 PERMANENTLY CLO ED TANK ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑g TANK REMOVED �Q FACILITY/SITE NAME WHERE LANK IS INSTALLED 6 �/ 71 Cc>t TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWN�TAANKM 10B. MANUFACTURED BY: C. YEAJ� D. TANK CAPACITY IN GALLONS: VQ II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,CDMPL@TE ITEM D. A. ® 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED M,2 LEADED ❑ 3 DIESEL N ❑3 CHEMICAL PRODUCT ❑4 OIL E V ® 1 PRODUCT ❑ d GASAHOL 11El5 JET FUEL 6 AVIATION GAS Fl 5 HAZARDOUS ❑BO EMPTY ❑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&C.A.S.N C.A.S.IC xill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,6 D A.TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEELIIRON. TANK ❑ 7 STArNLESS STEEL B ❑ 3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ l ALUMINUM ❑8 1DO%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL �UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ I RUBBERUNM ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLICLINING LINING ❑ 5 GLASS UNIIIG ❑6 UNLINED 1 0-95 UNKNOWN ❑ ISLINING MATERIAL COMPATIBLE WITH 100%METHANOL') ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑p 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION [:] 91 NONE f UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U_99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH 5 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIP£ C. MATERIAL A U 5 ALUMINUM A U CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%ME THANOL CO M PAI I BLE FRP A U 9 GALVANIZED STEEL A U 5 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. P S IVISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1, ESTWATED DATE LAST USED(MO/YR) 2�STII'I'AD QUANTITY OF 3 WAS TANK FILLED WITH CE REMAINING IN — -GALLONS INERT MATERIALI L]YES [D ND0 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED 6 SICINA.1 URF) y 0+4 E••. LOCAL AGENCY USE ONLY COUNTY A' JURISDICTION s AGENCY M FACILITY IDM TANK!D M LL Ll [610 r CURB NT OCAL AGENCY FACILITY 1D s APPROVED BY A' PHONE 4 WITH AREA CODE 6 a �- PERMIT NUMBER PERMIT APPROVAL DATE PER MFT EXPIRATIOU DATE CHECK s PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT s gy. i s 1 — FORM B J3-7-86). THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY