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AIV K Iia K PERMIT APPLICATION INFOTION <br /> COMPLETE A RATE FORM WITH THE FOLLOWING INFORMAWN FOR EACH TANK. <br /> 1 , <br /> MARK ONLY ❑ 1 NEW PERMIT D RENEWAL PER <br /> ONE ITEM D 5 CHANGE OF INFORMATION Z PERMANENTLY CLOSED LANK <br /> 2 INTERIM PER <br /> AMENDED PERMIT 6 TEMPORARY TANK CLOSURE <br /> FACILITY/SITE NAME WHERE TANK I8 INSTALLED: ❑R TANK REMOVED A� <br /> G z � FARM TANK_Y <br /> YES❑ VNO <br /> 1. TANK DESCRIPTION COMPLETE ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK 10 N �/ K to <br /> 8. MANUFACTURED BY: <br /> C. YEAR INSTALLED (C- <br /> D. TANK CAPACITY IN GALLONS: Cgq��bN�J <br /> 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.11),IS NOT MARKED,COMPLETE ITEM O. <br /> A. 1 MOTOR VEHICLE FUEL 0 2 PETROLEUM B. C. 1 UNLEADED 2 LEADED 'J <br /> O CHEMICAL PRODUCT 0 /OIL L ❑O DIESEL <br /> 1 PRODUCT 0 1 GASAHOL 0 5 JET FUELION N <br /> 5 HAZARDOUS BO EMPTY 95 UNKNOWN E3 2 WASTE El T METHANOL 99 OTHER(DESCRIBE IN REMID BEELOW) <br /> GAS <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED 8 C.A.S.N <br /> Kill, TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,8,C,8 D C.A S.IT <br /> A.TYPE OFJ�LGUU F WALLED Lj J SINGLE WALLED WITH EXTERIOR LINER <br /> SYSTEM Fuyl 2 S095 UNKNOWN <br /> NGLE WALLED 1 SECONOAM CONTAINMENT F]%OTHER <br /> B,TANK ❑ I STEEL/IRON 2 STAINLESSSTEEL El 7 FIBERGLASS 1 STEEL CLAD W/FIBERCAASS REINFORCED PIA$TN; <br /> { MATERIAL O 5 CONCRETE 6 POLYVINIL CNIOROF n )ALUMINUM OTT IOD%METHANOL COMPATIBLEFRP <br /> 9 BRONZE � 10 GALVANIZED STEEI %UNKNOWN <br /> ID 99 OTHER <br /> C. INTERIOR 0 1 RUBBER LINED 0 2 ALKYD LINING <br /> J EPDXY LINING 1 PHENOLICLINING <br /> LINING ❑ 5 GLASS LINING E16 UNLINED 1 1 <br /> El IS UMNG MATERIAL COMPATIBLE WITH 100%METHANOLT ❑%UWNOYNI <br /> ❑YES NO O 99 OTHER <br /> D. CORROSION ❑ I POLYETMLENE WRAP 0 2 TAR Ofl ASPHALT - - <br /> PROTECTION OVINYI WRAP /FIBERGLASS REINFORCED PLASTIC <br /> 5 CATHODIC PROTECDON 91 NONE 95 UNKNOWN <br /> 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE <br /> S. CONSTRUCTION A U I SINGLE WALLED A U 2 A U J GRAVITY A U 99 OTHER <br /> DOUBLE WALLED A U J LINED TRENCHU 5 UNKNOWN A U I STEEL/IRON A U 99 OTHER <br /> C. MATERIAL A U 2 STAINLESS STEEL A U J POLYVINYL CHLORIDE(PVC) A U A FIBERGLASS PIPE <br /> A U 5 ALUMINUM A U 6 CONCRETF <br /> A U 9 GALVANIZED SILEL A�95 UNKNOWN A U ] STEEL CLAD W/FHP A U B 100%METHANOL COMPA71plE FNP <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 Lpll S 2 INVENTORY RECONCILIATION P S J VAUOSE WELLS P S < ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS <br /> P 6 PRECISION TESTING P S ]PpESSugE iESirNG <br /> P S 91 NONE P S 95 UNKNOWN <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE " s 99 OTHER <br /> 1 ESTIMATED DATE LAST USED IMO/VHI -- <br /> ] ESiIMAi'EU OUANTHY OF J WAS TANK FILLED WITH <br /> SUBSIANCE REMAINING IN <br /> GALLONS INERT MATERIAL, ❑YES N0� <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MV KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAMF(PRINIFD A SHINAIIIHII <br /> •. <br /> LOCAL AGENCY USE ONLY oh E! <br /> COUNTYN JURISDICTION A, <br /> �7 AGENCY N FACILITY ID F <br /> TANK ID N <br /> CURRENT LOCAL AG L <br /> Y ID N <br /> APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER '--- <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK I UNT <br /> SURCHARGE AMT. FEE CODE <br /> RECEIPTa ■Y <br /> FORM 813.7-BBI THIS FORM MUST BE ACCOMPANIED BYA FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED TT I <br /> I <br /> -"-'------ - . DATA PROCESSING COPY <br /> Ii7D:i::Y191.,�TiP:."4::::L'4s,:�G'DiFIiiS�'ENVL.•PiG'lilLLtile;'.Wmme�v::�...I.u:,,...;�:.......ua.r.,�}, <br />