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I ANK IA ERMIT APPLICATION INFOR COMPLETE A S ATE FORM WITH THE FOLLOWING INFOflMA9FIONOR EACH TANK MARK ONLY 1 NEW PERMIT . ONE ITEM ❑G RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 2 INTERIM PERMIT N AMENOEOPERMITEl ❑ /PERMANENTLY CLOSED TANK 6 TEMPORARY TANK CLOSURE B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INBTALLED; I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN So SPECIFY FARM TANK VIE NO ------------- A. OWNERS TANK 10 N 3 - a Ll k B. MANUFACTURED BY C. YEAR INSTALLED U,y CIT IN I I. TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A),SANOT MARKED,COMPLETE ITEM D.©� A. I MOTOR VEHICLE FUEL 2 PETROLEUM A B. G N D CHEMICAL PRODUCT �4 OIL 1 UNLEADED 2 LEADED ] DIESEL � S HAZARDOUSF-1I PRODUCT 0 1 GASAHOL E]5 JET FUEL ❑M EMPTY 95 UNKNOWN E1 2 WASTE D I METHANOL [_]99 OTHER(DESCRIBE IN 6 AVIATION GAS D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OFF IN TEM D.BELOW) N HAZARDOUS SUBSTANCE STORED 6 C.A.S.N All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C.6 D C.A.S.N A.TYPE OF El I f IOLIBIE WALLED L_j 7 SINGLE WALLED MTH EXTERIOR LNER SYSTEM 2 SINGLE WALLED 9S OHERUNKNOWN ❑�SECONDARY CONTAINMENT �99 OTHER B.TANK I STEEL/IRON 0 2 STAINLESSSIEEL 03 FIBERGLASS 04 STEEL CULAS$D W/FIBERGREINFORCED PLASTIC MATERIAL ❑5 CONCRETE O 6 POLYVINYL CHLOROf O 1 ALUMINUM B IONIMETHANOLODWATIBLEFRP ID 9 BRONZE cl 10 GALVANIZED STEN O 95 UNKNOWN 99 OTHER C.INTERIOR ❑ 1 RIBBER LINED 02 ALKYD LINING T"� ❑ LINING ❑5 GLASS LINING 6 UNLINED 'J T EPDXY LINING / ICLINING ISLINING MATERIAL COMPATIBLE MTH 100%METHNIOL"' f�YES INMNOWN u E NO O SISI OTHER D.CORROSION ❑ I POLYETIBENE WRAP �2 TAq OR A$%MlT PROTECTION Q 3 A I.WRAP 04 FIBERGULSSREWFORQEDPLASTX; 5 CATHODIC PROTECTION 91 NONE UNKNOWN 0 99 OTHER IV, PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND.BOTH IF APPLICABLE A SYSTEM TYPE A LA I SLAC TION A U 2 PRESSURE B. CONSTRUCTION U 1 SINGLE WALLED A U — A U 7 GRAVITY A U 99 OTHER 2 DOUBLE WALLED A U 0 LINED TRENCH A U 95 UNKNOWN A U I STEEL/IRON w U 2 $TAWLES$SiEEL A U A U 99 OTHER C. MATERIAL A U S ALUMINUM 3 POLYVINYL CHLORIDE(PVC) A U A FIBERGLASS PIPE A U 6 CONCRETE A LA N STEEL CLAD W/FRP A U BIOBgy METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTFEL 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 5 2 INVENTORY RECONCILIATION P S 9 VADOSE WELLS P S A ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P 5 N PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE P 5 99 OTHER I. ESTIMATED GATE LAST USED IMO/yRl - 2 ESTIMATEDOUANTIIY OF SUBSTANCE REMAINING IN WAS TANK FILLED WITH GALLONS INERT MATERIAL' E]YES 0 NO� THIS FORM HAS BEEN COMPLETED UNDER PENALTY Of PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICAN P$NAME IPRINI f D A$IGNn 1 UI II'I 1 j :• LOCAL AGENCY USE ONLY COUNTY N JURISDICTION CTI� I AGENTCY• / ^�7 3® � FACILITY IDN —I �4` • TANK IDN 9 CURRENT LOCAL AGENCY FACILITY 10• - -I`_ I� 1_JI -L LLQ / APPROVED BY NAME PHONE EWITH AREA CODE PERMITNUMBER — -- PERMITAPPROVALDATE PERMIT EXPIRATION DATE CHECK PERMITAMOUNT — SURCHARGE AMT. FEE CODEC RECEIPTS BV� FORM B P-I-DBI THIS FORM MUST BE ACCOMPANIED BY A FACILITYJSITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA HAS BEEN FILED I -� -- -- •. DATA PROCESSING COPY • ri�il, '"419."..CY:iG:i:14 .• .ia�Xl!3SLLLUIe�sKn.c,•r _... -