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ANK I A PERMIT APPLICATION INFOR EACH TANK. <br /> ON <br /> COMPLETE A S TE FORM WITH THE FOLLOWING INFORMA FOR EA <br /> ^�. <br /> MARK ONLY 111 NEW PERMIT �3 RENEWAL PERMIT <br /> ONE ITEM 0 2 INTERIM PERMIT 5 CHANGE OF INFORMATION LYC <br /> IQ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE <br /> r PERMANENT LOSE <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED; ❑8 TANTS REMOVED <br /> �. TANK DESC`RIPTI ON COMPLETE ALL ITEMS-IF)UNKNOWN SO SPEC � FARM TANK-YESE] NO <br /> A. OWNERS TANK to N ' <br /> t <br /> C. YEAR INSTALLED B. MANUFACTURED BY: <br /> Q. TANK CAPACITY IN GALLONS: O <br /> II- TANK C: NTENTS IF(A.1),18 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D, L/ <br /> A. I MOTOR VEHICLE FUEL C)2 PETROLEUM <br /> iV <br /> 3 CHEMICAL PRODUCT F-] 4 OIL D C, 1 UNLEADED <br /> 2 LEADED 3 CDDIESEL <br /> 5 HAZARDOUS 80 EMPTY I PRODUCT © 4 GASAHOL Q5 JET FUEL a 6 AVIATION GAS <br /> D. If NOT MOTOR VEHICLE FUEL.ENTER NAME OF lV <br /> F g5 UNKNOWN ❑2 WASTE T METHANOL E]99 OTHER IOESCRIBE IN ITEM p-BELOW) <br /> HAZARDOUS SUBSTANCE ORED d C-A.&N <br /> x1ll, TANK CONSTRU ION MARK ONE ITEM ONLY IN BOX A,B,C,s o CA S.N. <br /> A. TYPE OF Q 1 DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER <br /> SYSTEM ❑ 2 SINGLE WALLED <br /> 1 SECONOAFfTCONTAINMENT 95 UNKNOWN <br /> 0 99 OTHER <br /> B. TANK [D I STEELlIRON �2 STAINLESS STEEL 3 FIBERGLASS 1 STEEL CLAD W/FIBERGLk%REINFORCED PLASTIC <br /> ? MATERIAL LJ 5 CONCRETE 6 POLYVINYL CHLORIDE T ALUMINUM 8 10091 METIIArIOt C0ITPATIBLE FRP <br /> 9 BRONZE 10 GALVANIZEDSTELI <br /> � <br /> 7 <br /> 095 UNKNOWN 99 OTHER <br /> C. INTERIOR L J I RUBBER LINED ALKYD LINING (� <br /> LINING 0 5 GLASS LINING f I'� 3 EPDXY LINING E] ,PHENOLIC LINING <br /> U 6 D INED <br /> IS LINING)MATERIAL COMPATI81-E WITH I METHANDL i 0%UNKNOWN <br /> 0 YES ❑ NO E]99 OTHER <br /> D. CORROSION � 1 POLYETHLENE WRAP � �2 TAR(TFT T <br /> PROTECTION ❑ f 3 VINYL WRAP 0 1 FIBERGLASS REINFORCED PLASTIC <br /> 4 CAPHOUIC PROTECTION ❑91 NONE <br /> El 95 UNKNOWN 099 OTHER <br /> V. PIPING INFORMATION CIRCLE All ABOVE GR NO. U IF UNDERGROUND.BOTH IF APPLICABLE ` <br /> A. SYSTEM TYPE A U I SUCTION <br /> B. CONSTRUCTION A U , A U Do RF A U 3 GRAVITY <br /> SINGLE WALLEU —" A U 99 OTHER <br /> A U 2 Do WALLED A U 3 LINED TRENCH A U 95 UNKNOWN <br /> A U 1 STEEL/YRON A U 99 OTHER <br /> C. MATERIAL A U SI AINL[S STFFt A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE <br /> A U 5 ALUMINUM A U 6 CONCRETE -- <br /> A U 9 GALVANIZED STEEL A U A U / STEEL CLAD W/FHP <br /> 95 UNKNOWN A U 6 ID09b METHANOL((7MPA71BLL FHP <br /> A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR FOR SECONDARY,A PRIM ARY BEAK DETECTION SYSTEM MUST BE CI <br /> I <br /> P S I VISUAL CHECK P S 2INV[NTORYRECONCILIATION P S 3 VA SE WELLS P S 4 ELFCTRONICMONITOR P RCLEO- <br /> P S 6 PRECISION TESTING P S I PRESSURE TESIG )I NO P S 95 UNKNOWN <br /> - 5 <br /> IN5 GROUND WATER MONITORING WELLS <br /> P S <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED I P S 99 OTHER <br /> pLACE <br /> I ESTIMATED DATE LAST USED IMOIYRI - - — — _ <br /> ESTIMAlEDOUANTII F — <br /> SIJBh1ANCF RFMAfNIN IN 3 WA$TANKF.ILLEO WITH <br /> INERT MATERIAL' 0YES <br /> HAS BEEN COMPLEIEf)UNOCR PENAL IY[)1 !'E- TO - GALLONS E] N[7� <br /> RJCIFIY,A IJ f� THE BEST T OF MY KN LEDGE.!S TRUE AANDCORRECT^'J <br /> APPLICANT S NAME <br /> THIS FORM WRINII ON SIISNA TtJI4E 1 <br /> DR E I <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N <br /> EE <br /> AGENCYN FACILITY ID M�J /TANK IDN <br /> F0 <br /> CURRENT LOCA).AGENCY FACILITY tD a . = <br /> if L/ <br /> APPROVED BY NAME <br /> J PHONE N WITH AREA CODE <br /> �. <br /> PERMIT kU E <br /> PERMIT APPROVAL DA PERMIT EXPIRATION DATE <br /> 1 CHECK N PERMIT AMOUNT --- <br /> SURCHARGE AMT- FEE CODE <br /> RECEIPT 1 BT' <br /> ORM a Ia I BBI THIS FORM MUST BE AGCpMPANIEp BY A FACILITY/SITE APPLICATION, FO H <br /> R M 'A',UNLESS A CURRENT FORM AS BEEN FILED <br /> DATA PROCESSING COPY (� <br /> �_6 <br /> li— <br /> &ileuur: <br />