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COMPLETE IK PERMIT APPLICATION IN PARATE FORM WI THE FOLLOWING INFO ATION MARK ONLY ❑ 1 NEW PERMIT ION FOR EACH TANK $� ONE ITEM ❑J RENEWAL PERMIT ❑2 INTERIM PERMIT S CHANGE OF INFORMATION FACILITY/SITE NAME WHERE TANK IS INSTALLED /AANENDEU PERMIT 6 TEMPORARY TANK CLOSURE ❑T PERMANENTLY CLOSED TANK ❑ I• TANK DESCRIPTION / . ❑e TANK REMOVED COMPLETE ALL 1 � O A. OWNERST TEMB-IF UNKNOWN— p`O'I FARM TANK-LES❑ NO ❑ ANK IDN SO SPECIFY C. YEAR INSTALLED B. MANUFACTURED BY: to I1. TANK CONTENTS D. TANK CAPACITY IN GALLONS: �y IF(AT)•IS MARKED,COMPLETE ITEM C.IF A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM IF( 1) IS NOT MARKED,COMPLETE ITEM D. ❑3 CHEMICAL PRODUCT ❑1 OIL B. A ❑S. C. ❑ t UNLEADED ❑2 LEADED N T HAZARDOUS ❑M EMPTY ❑95 UNKNOWN &I PRODUCT ❑N GASAHOL ❑ J DIESEL `�- 0. IF NOT MOTOR VEHICLE FUEL ENTER NAME OF ❑2 WASTE S JET FUEL ❑ fi AVIATION GAS N HAZARDOUS SUBSTANCE STORED A C.A,S.N ❑ F METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) KIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BO%A,8,C.8 D C.A.S.a. A SYSTEMF ❑ SINGLE WALLED ❑JSNGU WALLED MIN EXTERIOR LWER ❑1 SINGLE WADED 1 SECONDARr El 95 UNKNOWN ❑ cDIIruNMEnr E. TANK ❑ 1 STEEUIRON ❑99 OTHER 1:15 CONCRETE ❑2 STAINLESS STEEL MATERIAL ❑J FlBERCU$S El9 BRONZE ❑6 POLYVINYL CILORNIF ❑ /ALUMINUM ❑N STEEL CHAD WYFIBEAGLASSNEIT RCED R9TIC ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 0fl FTIUNOLCOMPATIREFRP C. INTERIOR ❑ 1 BUBBEBLINED 99❑ --- LINING ❑5 GLASS LALLING 2ALKYO LINING ❑ ❑J EPO 6 UNLINED IryLINING ❑/PHENOLIC LINING ❑SWING MAIEflUI GDMPAi I BLEWITHIWNMETHNIOLI ❑ ❑� ❑�ONOWN D. CORROSION ❑ I POLYETILENE WRAP YES ❑ PROTECTION ❑2 FAR OR ASRMLT THER ❑ 5 CATHOOICPROTEChON ❑J VINYL WRAP 1 ❑91 NONE ElFIBERGLASS REINFORCED PLASTIC IV. PIPING INFORMATION 1:195 UNKNOWN ❑99 OTHER CIRCLE A IF ABOVE GROUND U IF UNDERGROUND,BOTH IF APPLICABLE A SUCTION SYSTEM TYPE A U 1 - B. CONSTRUCTION A U I SINGLE W A U 2 PRESSURE _ A U 9 GRAVITY ALLED A U 1TOWILE A U A U 99 OTHER A U I STEEUIROry --�--- J LINED TRENCH A U 95 U C. MATERIAL A U b ONC ESB SiEFa A UNKNOWN A U 990THER A U 5 ALUMINUM U 7 POLYVINYL CHLORIDE PVC A U 6 CONCRE TF ( 1 A U A FIBERGLASS PIPE A U 9 GALVANIZEDSTLEL A U 95 UNKNOWN A U / STEEL CLAD W/FHP A U 99 OTHER A U 8 10014 METHANOL COMPATIBLE FRP V. LEAK DETECTION SYSTEM CIRCLE P FORPRIMARY ORS FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUAL CHECK P S 2 PRESSINVENURE TEORY RSCOGCILIATION 1 5 9 VADOSE WELLS P S A ELECTRONIC MONITOR P S S GROUND WATER ST BE CIRCLED. WELLS P 9 6 PRECISION TESTING P 5 7 PRESSURE TESTING P 5 91 NONE P 5 95 UNKNOWN VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE " S OTHER 1 ESTIMREO DATE LAST USED IMO/YRI — — T ESNMATEDOUANTIIYOF SOBSTANCE REMAINING IN J WAS TANK FILLED WITH THIS FORM F1gS BEEN COMPLETED UNDER PENAL TY --�—'— GALLONS INERT MATERIAL ❑YES ❑NO OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APP;K�Lh 1 c NAME IPRINIFD A SKINA IIPK I Uq E!,. P LOCAL AGENCY USE ONLY COUNTY, JURISDICTION N T� AGENCY- FACILI Y ID 1 TANK 10 N 1 CUR OCAL AGENCY FACILITY IO• -- APPROVED BY NAME PERMIT NUMBER - PRONE 1 WITH AREA COpE PERMIT APPROVAL DATE PERMIT EXPIRATION OATS _ CHECK 1 PERMIT AMOUNT - --SURCHARGE AMT. FEE CODE RECEIPT, - PDRAI B IJ'TBBI THIS FORM MUST BEACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMW - DATA PROCESSING COPY HAS BEEN FILED .i �W'.CRDR t:;:ii.7�,"..:+.;Irw oAz7:7flr,AeGiurt:t,,