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MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANCE OF INFORMATION a I PERMANENTLY CLO. D TANK <br /> ONE ITEM 2 INTEHIMPLAmil Ll l AMENDED PERMIT 6 TEMPORARY TANK CLOSURE �B TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK 15 INSTALLED: RIA TANK-YES NO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I O <br /> A. OWNERS TANK 10 N B MANUFACTURED BY: <br /> C. YEAR INSTALLEO i a 0 TAM(CAPACITY IN GALLONS', <br /> 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM 0. (�} <br /> A, 0 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B 0 1 UNLEADED [D2 LEADED 3 DIESEL0 3 CHEMICAL PRODUCT 4 OIL 1:11 PRODUCTtC <br /> Q A GASAHOL ❑5 JET FUEL 0 6 AVIATION GAS fV <br /> ❑ 5 HAZARDOUS 80 EMPIY [T] 9S UNKNOWN L] 2 WASTE I METHANOL 11 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME CIT <br /> HAZARDOUS SUBSTANCE STORED&C AS, N C.A S N <br /> xill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,i D <br /> A TYPE OF I DOUBLE WALLED 3 SINGLE WALLEO WTH EXTERIOR LlNFR F-195 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED T SECONDARY CONTAINMLNI 99 OTHER <br /> I SIEEUIRON Fl 2 SIAINL ESS STEE I m 3 FIBERGLASSI STEEL CLAD WIFIBEWAASSREINFORCED PLASTIC <br /> B. TANK Fl <br /> MA7MATERIAL �I—J 1 5 CDNCAEIE F-16 POLYVINYL CHLOR11* m I ALUMINUM �E 100%METHANOL COMPATIBLE FOP <br /> 11 9 BRONZE 10 GALVANIZED STEI, 95 UNKNOWN 99 OTHER <br /> C. INTERIOR <br /> I RUBBER LINED —..._ ❑ 2 Af!(YO UNINf, (� 3[POO LINING � I PHENOLIC LINING <br /> � <br /> LINING ❑ 5 GLASSLINING lf� 6 UNLINED 95 UNKNOWN <br /> El IS LINING MATERIAL COMPATIEld WITH 100'1,METHANOL 0 YES El NU 0 99 OTHER <br /> 0, CORROSION ❑ 1 POLYETHLENE WRAP 7 TAR OR A". AI I Ej 3 VINYL WRAP 1 FIBERGLASS FIFINfORCLOPLASTIC <br /> PROTECTION 5CATHOOICPROfECi70N ❑ 91 NOW Ll 9S UNKNOWN ❑ 99OIHER�---,---_—__.-- <br /> IV. PIPING INFORMATION CIRCLE A II ABOVE GROOUNO, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSl1Rf A U I GRAVIIY A U 99 OTHER <br /> 9. CONSTRUCTION A U I SINGLE WALLED A U ? DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 011,4FR <br /> A U 1 STEEL/IRON A U SfAINI f SS tiiI f A U I POLYVINYL(4ILORIf)f O'VCl A U ! FIBERGLASS PIP1 <br /> C. MATERIAL A U ', ALUMINUM A U 6 CONCW II A U SILT[ CIADWlL111' A U B 100%METHAN0LC0MPATltkLE THP <br /> A U '7 G,AT VANI II.I,',T I.I I A U 'IS UNKNOWN A U 'N 011llld __-- <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY OR S FOR SECONOAAY,A PRIMARY LEAK DETECTION SYSTEM MUST 13E CIRCLED. <br /> P S I VISUAL CHECK P S 2 INVENTORY RFCONCII VA IrON P S I VAU17Rl WEI.I.`, P S I ELIC1RONIC MONIT011 P S 5 GROUND WATFR MONITORING WFL.LS <br /> P S 6 PRECISION TESTING P g 7 PRESSUHE IF.S.IING P S Al' NONE P 5 95 UNKNOWN P S 99 OTHER <br /> VI, INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 7 ISIIMATFIIOATELASIUSFIIIM[71YITI 1 !`iTIR1AdfI7ihIANfIIYL)I I WAS TANKf.IILFUWllfl <br /> `Ajll'.141,11 14'MAINWC,IN I INERT MAPERIAL (1 <br /> ' <br /> C YL S, [ N <br /> GALLONS <br /> THIS FORM HAS BEEN CO+�lF'LETL!)ONOI IZ PI NAL 0 r, I'! 1{-11,.11dY.ANO To THE BEST OF MY KNOWLEDGE.IS TF{l2(=AND('OI7F7l f;f <br /> APPLICANT`;NAI,11 JVQIN11I1(',II,14f.l 1.1. - `� <br /> I)Ar f I <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY 10 N TANK IO N <br /> -ED H EFTI 1 1 D771021 L� 1 11411 <br /> CURRENT LOCAL AGENF�yA—rC`ILITY ID• APPROVEO BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER _. PERMIT APP.ROVAL OATS P AMIT PIRATION q <br /> 44 <br /> � � <br /> CIiECK.r PERMIT AMOUNT SURCHAAGE AMT FEE CODE RECEPPT f BY: <br /> FORM B 17.7.98) THIS FORM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FORM 'A',UNLESS A CURRENT FORY'A' HAS BEEN FILED <br /> - DATA PROCESSING COPY <br /> ) <br />