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STATE7 RNIJ WATER RESOURCE$,CONTR�BOARD ..:.. FORM ' UND GROUND STORAGE TANK PR RAM ' TAN ` / TANK PERMIT APPLICATION INFORMATION ' 6OM BETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FO CF1 TANK. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 MANENTLY CLOSEQJAUK- _ + ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLO E 8 TANK REMOVED Qy FACILITY/SITE NAME WHERE?ANK IS INSTALLED: ' 17o 11-11)LoClf' ZW TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY U CA: A. OWNERS TANK IDR B. MANUFACTURED BY: C. YEAR INSTALLED (l/C D. TANK CAPACITY IN GALLONS: So 57�Q II. TANK CONTENTS IF(A.1) MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMP . E ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL 2 PETROLEUM & C. UNLEADED 2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL 6'(PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL 6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 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 8 C.A.S.R C.A.S.R: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A.TYPE OF ❑ 1DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE r-16 POLYVINYLCHLORIDE F-17 ALUMINUM 8100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBERUNED ❑2 ALKYD LINING ❑ 3 EPDXY UNING ❑4 P NOLIC LINING LINING ❑5 GLASS UNING ❑6 UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH ion METRANOL7 ❑YES ❑ NO ❑99 OTHER r ON ❑ 1 POLYETHLENEWMP ❑2 TMORASPHALT ❑ 3 WIIAP ❑/FIBERGLASS REINFORCED PLASTIC ION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 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 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U I SIN GL D A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A kj5 UN A U 99 OTHER U 1 STEEL/IRON A U IN TEEL U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 9/ NONE C. MATERIAL A U 5 MINUM A U 6 COKCRETE A U 7 STEEL CLAD W/FRP A U 8 1 OD%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 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. P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S I ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURETESTING P S 91 NONE P NKN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN OL•LLONS INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION# AGENCY R FACILITY ID R TANK ID# 3 9 3 fa] 3] 1 O 1 o / 9 3 b D I o I (- CURRENT LOCA.AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE GD/'..� Z .z(o C PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: //i3/8 9 FORM B(6-29-BB) THIS FOflM MUST RE ACCOMPANI A FACILITYISITE APPLICATION, FORM 'A',UNLESS A ..RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY