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I HIV K 1 AA6 PERMIT APPLICATION INFO TION <br /> COMPLETE A RATE FORM WITH THE FOLLOWING INFORMAWN FOR EACH TANK. },� o <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT n <br /> ONE ITEM 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSEPANK <br /> 2 INTERIM PERMIT AMENDED PERMIT <br /> FACILITY/BITE NAME WHERE TANK IS INSTALLED: ❑6 iEMPOFEg%fry�TAN'K.CLOSURE B TANK REMOVED / <br /> I. TANKOESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY ��77zf(/jy � FAflM TANK-YES NO <br /> A. OWNERS TANK IDN <br /> B. MANUFACTURED BY: G, <br /> C. YEAR INSTALLED 7 <br /> 11. TANK CONTENTSIF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),S NOT MARKED,COMPLETE ITE 0000 C77Y L [J <br /> L <br /> A. 1 MOTOR VEHICLE FUEL 0 2 PETROLEUM A <br /> B. C. N <br /> 3 CHEMICAL PRODUCT E] /OIL I UNLEADED <br /> 2 LEADED [1]3 DIESEL � <br /> 5 HAZARDOUSBp EMPTY 95 UNKNOWN I PRODUCT 1 GASAHOL 5 JET FUEL 6 AVIATION GAS N <br /> 2 WASTE 7 METHANOL E]99 OTHER(DESCRIBE IN ITEM D.BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED 6 C.A.S.N <br /> x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.8 D C.A.S.N. <br /> A TYPE OF ❑ I DOUBLE WALLED Lj J SINGLE WALLED WITH EXTERIOR LINER <br /> SYSTEM 2 SINGLE WAILED95 UNKNOWN <br /> K SEC <br /> IAF ❑ ONDARY CONIAINMENT 99 OTHER <br /> B.TANK} EXl I STEEL/qqN 2 STAINLESSSTEEL 03 FIBERGLASS <br /> FL--Jy 5CONCRETE /STEEL CUDWIRBERG(ASS REWWRCED"TIC MATERIAL 6 POLYVINYL CNLORIOH J ALUMINUM 1:1B 100%METHANOL COMPATIBLEFRP <br /> 9 BRONZE El 10 GALVANIZEDSTEEI 95 UNKNOWN O 99 OTHER <br /> C. INTERIOR <br /> ❑ I RU El <br /> 2 ALKYD LINING J EPDXY LINING El/PHENOLICUNING <br /> LINING ❑ 5 GLASS LINING 6 UNLINED 1 I <br /> E] IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL, YES 96 UNKNOWN <br /> NO 99 OTHER <br /> D. CORROSION ❑ I PGLYETHLENEWMP � �2 TAR OR ASPHALT <br /> PROTECTION ❑3VINYL WRAP 1 FIBERGLASS REINFORCED PLASTIC <br /> 5 CATENJOIC PIgiECigN 91 ERNE 95 UNKNOWN <br /> 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUNUUO IF UNDERGROUND.BOTH IF APPLICABLE <br /> A SYSTEM TYPE A U 1 SUCTION <br /> AID PRESSURE A U J GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION AI SINGLE WALLED A U z <br /> DOUBLE WALLED A U ]LINED TRENCH A®5 UNKNOWN <br /> AIV 9 A U 99 OTHER <br /> I STEEL/IRON <br /> C. MATERIAL A U ' STAINLESS STFFI A U 3 POLYVINYL CHLORIDE(PVC) A U A FIBERGLASS PIPE <br /> A U 5 ALUMINUM A U 6 CONCRETE <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U I STEEL CLAD W/FNP A U B 100%METHANOL COMPATIBLE FHP <br /> 9 <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 />�� R S I VISUAL CHECK ° 2 INVENTORY RECONCILIATION P S J VAOOSE WELLS P S A ELECTRONIC MONITOR p g 5 GROUNDWATER MONITORING WELLS <br /> P 6 PRECISION TESTING P 5 'PRESSURE TESTING <br /> P 9 91 NONE P S 95 UNKNOWN <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE ° s OLHER <br /> I ESTIMgTEp OgiE LAST USED IMG/YRI -- <br /> TESTIMaiED DDANTIIY Of <br /> � SURNI ANCE REMAINING IN J WAS TANK EILLED WITH <br /> GALLONS INERT MATERIAL' YES N0� <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY Of PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT <br /> APPLICANT'S NAME IPI11N1 F D rt SIGNa 1 UIJI I <br /> I j <br /> LOCAL AGENCY USE ONLY B <br /> COUNTY A JURISDICTION, - <br /> AGENCY, FACILITY ID N <br /> TANK K <br /> / _ � � � S 'b 0 O l <br /> CURRENT LOCAL AGENCY FACILITY 101 _ -__ <br /> �i� U �� APPROVED BY NAME <br /> V PHONE A WITH Aq CODE _ <br /> PERMIT NUMBER — <br /> PERMITAPPROVALOATE PERMIT EXPIRATION DATE <br /> CHECK, PERMIT AMOUNT <br /> SURCHARGE AMT. FEECOOE <br /> RECEIPT, B <br /> FORM B F67.88I THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATIaIi, FO R M 'A',UNLESS A CURRENT FORMA' HAS BEEN FTLED <br /> I <br /> DATA PROCESSING COPY <br /> � a <br />