BILLING - Laserfiche WebLink

Home Browse Search

TANK TANV"RMIT APPLICATION INFORMWN ;e COMPLETE ASEP E FORM WITH THE FOLLOWING FORMAT) R EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYCLO ONE ITEM F-12 INTERIM PERMIT f-] A AMENDED PERMIT E]6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARMTANK-YES❑ NOEjj-' -7 s� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 10 A. OWNERS TANK IDN R. MANUFACTURED BY: L( C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 00 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. N A. I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM C El UNLEADED ❑2 LEADED DIESEL `� ❑ 3 CHEMICAL PRODU8CT ❑ d OIL I PRODUCT 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS N ❑ 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.N C.A.S.A. .III. TANK CONSTRUCTION ARK ONE ITEM ONLY IN BOK A,B.C.BD A TYPE OF ❑ 1 DOUS-E WALLED 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM r-1 SYSTEMWALLED ❑/ CONOARY CONTAINMENT ❑99 OTHER _. ❑ I STEEl11fgN ❑2 STAT SS STEEL ❑3 FIBERGLASS ❑ISIEEL CIIDW/FIBERGLASS REINFORCED RAM B.TANK ❑ 5 CONCRETE ❑6 POLrvINVI DAK ❑ 7 ALUMINUM ❑8100%METHANOL COMPATIBLERP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED EL ❑ 95 UNKNOWN ❑99 OTHER ❑ I RUBBER LINED ❑2 ALKYD LINING3 EPDXY LINING ❑/PHENOLCLIMNG C. INTERIOR LINING F-15 GU$SUNING ❑6 UNLINED I E]95 UNKNOWN E] IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL' E$ ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYETHUNE WRAP ❑2 TAR OR ASPRALT ❑ 3A P ❑N FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE El95 UNKWRAN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGRO D,BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVhz A U 99 OTHER B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRbkcH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYLORIDE(PVC) A U C FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CUD W/ A U 8100%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 EAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P S A ELECTRONIC MO OR P 5 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 5 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S %OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE LAST USED IMOIYPI 2 ESTIMATED QUANTITY OF 3 WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS 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 K SIGNA Tl IRF I Df}E i LOCAL AGENCY USE ONLY COUNTY* JURISDICTION N AGENCY N FACILITY 10 N TANK ID N aM = = �01 ,11A,31TM 1*0101013 CURRff OOCCALAGENCY FACILITY 1011 ^ APPROVED YN�LM Y� PHONE N WITH AREA CODE PERMIT NUMBER /L� (�/ 7 PERMIT APPROVAL DATE /fi RMIT UPIR'ATIIO`N DATE i CHECKN PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT• BY: i I FORM B(3 7-M) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM'W HAS BEEN FILED • 11ATA PROCESSING COPY 0