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I HIV K 1 j+ ERMIT APPLICATION INFORRR� <br /> COMPLETE A ATE FORM WITH THE FOLLOWING INFORM ION <br /> FOR EACH TANK. �a1N f , <br /> MARK ONLY clI NEWPERMD JRENEWAL PERMIT <br /> ONE ITEM 5 CHANGE OF INFIX9MATK)N El T PERMANENTLY CLOSED TANK <br /> 21NTERIM PERMIT / AMENDED PERMIT <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: ❑6 TEMPORARY TANK CLOSURE 08 TANK REMOVED <br /> L TANK DESCRIPTION COMPLETE ALL ITEMS.IF UNKNOWN— -S r AqM TANK-YES p <br /> SO SPECIFY _0 <br /> A. OWNERS TANK IDM 93 //l — � 10 <br /> B. MANUFACTURED BY: <br /> C. YEAR INSTALLED <br /> II. TANK ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.D. <br /> ISNOTMARKED.COMPLETE ITEM D. <br /> A. A <br /> 1 MOTOR VEHICLE FUEL 2 PETROLEUM (V <br /> B. O ❑ I UNLEADED LEADED .7 <br /> 3 CHEMICAL PRODUCT � 1 OIL �J DIESEL <br /> 5 HAZARDOUS BO EMPTY 95 UNKNOWN O I PRODUCT O 1 GASAHOL 5 JET FUEL 6 AVIATION GAS N <br /> 2 WASTE T METHANOL 99 OTHER(DESCRIBE IN ITEM D.BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED A C.A.S.N <br /> .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D <br /> A TYPE OF 1�10U61E WALLED Lj 7 yryC,U WALLED W1TN EXTERIOR LINER y� KE ,N <br /> SYSTEM E2/2SINGLE WALLED 1 SECONDARYCONTANMENT <br /> 0 99 OTHER <br /> B. TANK 1STEEL/IRON 2 STAINLESS STEEL 1STEEL CIADW/FIBERGLASS BERfORCED PLASTIC <br /> .j MATERIAL ❑5 CONCRETE J ALUMIN SS <br /> 6 POLYVINYL CRLGRIpl ]µUMINUM B IBBK MERLW <br /> 9 BRONZE IO GKVANIIED SIEEI OL COMPATIBLE FIP <br /> 95 UNKNOWN Ej 99 OTHER <br /> C.INTERIOR ❑ 1 RUBBER LINED 2µKYp LINING " <br /> 7 EPDXY LINING 1 PHENOLIC LINING <br /> LINING ❑5 GLASS ENING �6 UNLINED I t <br /> ISLNING MATERIAL COMPATIBLE NTH IBB%METHANOL+ �95 KNONI <br /> YES NO E]99 OTHER <br /> D. CORROSION I POLYETNLENE WRAP p TAR Ofl A5RML7 <br /> PROTECTION E] �J INYIWMP �IfIBERGUS$REINFORCED PIA$ilO <br /> S CATHODIC PROTECTN)N 91 ROBE <br /> 95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A SYSTEM TTPE A LA I SUCTION A U 2 PRESSURE <br /> B. CONSTRUCTION A U I SINGLE WALLED A U — A U ] GRAVITY A U 99 OTHER <br /> 2 OWIAE WALLED A U ] LINED TRENCH A U 95 UNKNOWN <br /> © U I STEEL/IRON A U 2 SIAINLESSSIEEI A U ] A U 99 OTHER <br /> C. MATERIAL A U 5 ALUMINUM POLYVINYL CHLORIDE LPVCI A U K FIBERGLASS PIPE <br /> A U 9 CONCRETE A U 7 STEEL CLAD W/FNP <br /> A U 9GALVANIIED STEEL A U 95 UNKNOWNA U 0IWI6 METHANOL COMPATIBLE FHP <br /> A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY.A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S ] VgppSE WELLS P S I ELECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELLS <br /> P 5 6 PRECISION TESTING P s i PRESSURE TESTING <br /> P 5 91 NONE P 5 95 UNKNOWN <br /> VI. INFORMATION ON TANK PERMANENTLY P S 99 OTHER <br /> CLOSED IN PLACE <br /> I ESTIMATED DATE UST USED IMO/YHI - _ <br /> — 2 ESTIMATED QUANTITY OF <br /> SUBSTANCE REMAINING IN ] WAS TANK EILLED WIIH <br /> __.. ___ GALLONS INERT MATERIAL' YES NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENAL 7Y <br /> IPRINI FD A 9GNn I Ipil I OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT <br /> APPLICANTS NAM( <br /> DAY <br /> E! <br /> I j P <br /> LOCAL AGENCY USE ONLY <br /> COUNTY F JURISOICTION N <br /> AGENCY N FACILITY ID N <br /> 3 � 43 z-v TANK ID N <br /> CURRENT LOCAL AGECY FACILITY 10 N <br /> I APPROVED BY NAME PHONE N WITH AREA CODE <br /> LL-� <br /> GPERMIT APPROVAL DATE PERMIT EXPIRATION DATEPERMITAMOUNT <br /> SURCHARGE AMT, FEE CODE <br /> RECEIPT F 25-BY: <br /> FogMel7rBel THIS FORM MUST BE ACCOMPANIE08YAfACILITYISITE APPLICATION, FORM 'A',UNLESS ACURgENT FORY'A' HAS BEEN FILED J I <br /> DATA PROCESSING COPY <br />