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AN K TA <br /> TE!RMIT APPLICATION INFOR ION <br /> COMPLETE A S FORM WITH THE FOLLOWING.I ORM- <br /> MARK ONLY Q t NEWPERMrT OR EACH TANK. <br /> ONE ITEM 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION <br /> 2 INTERIM PERMIT 4 AMENDED PERMITElT PERMANENTLY CLOSED TANK <br /> FACILITY/BITE NAME WHERE TANK IS INSTALLED: 6 TEMPORARY TANK CLOSURE <br /> _ 08 TANK REMOVED <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY a FARM TANK-YES 0 NO <br /> A- OWNERS TANK iD N ' <br /> C. YEAR INSTALLED 13. MANUFACTURED BY to <br /> D. FANK <br /> CAPACITY IN GALLONS: <br /> C. , <br /> If. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE'ITEM CIF(A1),IS NpT MARKED,COMPLETE ITEM D, <br /> A I MOTOR VEHICLE FUEL 0 2 PETROLEUM <br /> F-� <br /> 3 CHEMICAL PRODUCT � C El 1 UNLEADED� OIL LJ 2 LEAPED 3 DIESEL <br /> 4-tPRODUCT <br /> � <br /> 5 HAZARDOUS 0 4 GASAHOL a 5 JET FUELtU <br /> 86 EMPTY ❑95 UNKNOWN E]2 WASTE T METHANOL B AVIATION CAS <br /> 11 <br /> D, IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF d 99 OTHER(DESCRIBE IN ITEM D.BELOW) <br /> HAZARDOUS SUBSTANCE STOR D&C-A.S.K <br /> dI1. TANK CONSTRUCTI N MARK ONE ITEM ONLY IN BOX A.B,C.A D CAS 0 <br /> A. TYPE OF 0 1 DOU%E WALLED Q 3 SINGLE WALLED WITH EXTERIOR LINER <br /> SYSTEM ❑ 2 SINGLE WALLED <br /> ❑ 4 SECONDARY CONTAINMENT 95 UNKNOWN <br /> _ Q 99 OTHER <br /> TANK nElI STEEL118ON 2 STAINLESS STED <br /> .� B MATERIAL Ej cl 9 BRONZE 5 CONCRETE ❑3 FIBERGLASS Q 4 STEEL CLAD WIFIBFFGLASSREINFORCED PLASTIC <br /> 6 POLYVINYL CH 0 T ALUMINUM El9 1W%METHANOL COMPAIIBLE FEW <br /> 10 GALVANIZED STEEL <br /> J'� E1 95 UNKNOWN 099 OTHER <br /> C. INTERIOR � l I RUBBER LINED El KYD LINING <br /> LINING 0 5 GLASS LINING f l 6 U INED 3 E� LINING E] 1 PHENOLIC LINING <br /> � ± � <br /> DIS LINING MATERIAL COMPATIBLE WITH I ME_1HAN&', 0 95 UNKNOWN <br /> YES D NO 0 99 OTHER <br /> 5 CATHODIC PROTECTION 91 NONE D. CORflOS10N a I POLYETRLENE WRAP 0 2 TAR OR I -f�T <br /> PROTECTION U 3 VINYL WRAP 0 4 FIBERGLASS REINFORCED PLASTIC <br /> � <br /> 095 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE II AE30V[GRO U. U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A SYSTEM TYPE A u , SUCTION <br /> A U 2 PRESSU E A U 3 GRAVITY _ <br /> B. CONSTRUCTION A U I SINGLE WALLED A U ? DOUBLE LLFO A U 99 OTHER <br /> --- ----- U 3 LINED TRENCH A U 95 UNKNOWN <br /> A U I SIEELIIRON A U A U 99 OTHER <br /> C. MATERIAL STAINLESS.S FFI A U 3 POLYVINYL CHLORIDE IPVCI A U 4 FIBFRGLA$S PIPE <br /> A U 5 ALUMINUM — — <br /> A U 6 CONCRETE A U 1 STEEL CLAD WFFHP <br /> A U 9 GALVANIZED STILL A U 95 UNKNOWNA U 99 QTHEF; A U 9 TOO%METHANOL CUMF'AIIIi1.F FHP <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S OR SECONDARY•A PRIMARY LEAK DETECTION SYSTEM MUST BI �^ <br /> P S I VISUAL CHECK P S 21NYBNTQlTY?1ECQNCILIATION P CIRCLED. <br /> P S 6 PHECISION TESTING P S 7 PRESSURE Tk STING 5 11, I- ELLS P S 4 ELECTRONIC MONITOR p <br /> P S 91 NONE p P S 95 UNKNOWN S 5 GAQUND WATfH MONITORING WELLS <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE P s 99 OTHER <br /> I ESTIMATED DATE LAST USF.D[MQlYHI - - —— <br /> F;iTIMA1FD OUANI --_ ----- <br /> SHIP,IAPI(;k HE MAINING IN a1 l WAS.FANK FILLED WITH <br /> INERT MATERIAL', � YES <br /> THIS FORM HAS BEEN COMPLETED UNDER PENAL TY uI PE!?JUgK AND h) THE BESTOFMY KNOWLEDGE• IS TRUE AND CORRECT <br /> ry <br /> CT {! <br /> APPLICANTS NAME W8IN1111,1 SHiNA IIIYII LN -L] <br /> DA� EI•. <br /> -��---� <br /> LOCAL AGENCY USE ONLY J <br /> • CO�U�JNTY/M � JURISDICTION w <br /> AGENCY w FACILITY ID <br /> TAMC 10 K <br /> ` CURRENT LOCALNCY F IL TY ID 0 <br /> APPROVED 8Y NAME <br /> PHONE 0 WITH AREA CODE <br /> -I PERMIT NU BER <br /> PERMIT APPROVAL.DATE PERMIT EXPIRATION DATE <br /> CHECK I: PERMIT AMOUNT ---- <br /> ti SURCHARGE AMT. FEE CODE <br /> RECEIPT it BY_ <br /> \ FORM B 0.7--as) THIS FORM MUST BE ACCOMPANIED BY A FACILITYTSfTE APPLICATION, FORM `A', ~ <br />- -- DATA PROCESSING COPY UNLESSACURRENi FORY'A' KASBEENFILED <br /> i - \4L <br />