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TANK TA19PERMITAPPLICATION INFOROTION <br /> I COMPLETE A SEPARATE FORM WITH THE FOLLOWI INFORMA N FOR EACH TANK. <br /> MARK ONLY El I NEW , <br /> PERMIT 3 RENEWAL PERMIT <br /> El ONE ITEM 1 INTERIM PERMIT A AMENDED PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK <br /> 6 TEMPORARY TANK CLOSURE El B TANK REMOVED O <br /> FACILITY/BITE NAME WHERE TANK IS INSTALLED: f C <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN— FARM TANK-YES NO <br /> SO SPECIE 7 <br /> A. OWNERS TANK IDN 0 <br /> CYEAR INSTALLED R. MANUFACTURED BY- <br /> D. <br /> TT <br /> TY IN GALLONS: <br /> II. TANK ONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A D,ISNoMARKNK T D,COMPLETE ITEM V <br /> A. I MOTOR VEHICLE FUEL F-1 2 PETROLEUMJ� <br /> B. C <br /> EV <br /> 3 CHEMICAL PRODUCT E34 OIL �(/ El UNLEADED 2 LEADED 3 DIESEL <br /> BO EMPTY <br /> 5 HAZARDOUS LJ ' PRODUCT Ej 1 GASAHOL 0 5 JET FUEL 6 AVIATION GAS N <br /> -95 UNKNOWN F]2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D.BELOWI <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED A C A.S.N <br /> .111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN SOX A.B.C,8 D CA.S.N. <br /> A TYPE OF ❑ 1 UOUBU WALLED Lj 3 SINGLE WALLED WITH DGERIOR LINER %UNKNOWN <br /> SYSTEM 2SINGLE WALLED El 1 SECONOAHYCONTMNMENT <br /> 99 OTHER <br /> S.TANK ❑ 1 STEEL/IRON 2 STAINUSSSTEEL 3 FIBERGLASS 1 STEEL CLAD W/FIBEpCAA$S REu1FORCED PIA$11C <br /> MATERIAL O 5 CONCRETE 6 POLYVINYL CILORIOF 7 ALUMINUM B STEEL LAD W/FNOL COMPATISLEFW <br /> 13 9 BRONZE 10 GALVANIZED STEEI %UNKNOWN 99 OTHER <br /> C.INTERIOR ❑ I RUBBER LINED 2 ALKYO UN1NG <br /> I_J 3 EPOKYDNING K PHENOLIC LIMNG <br /> LINING ❑ 5 GLASS LINING 6 UNLINED I I 95 UNKNOWN <br /> El IS LINING MATERIAL COMPATIBLE WITH IBK%METRANOLT <br /> ❑ YES []NO 99 OTHER <br /> D.CORROSION <br /> PROTECTON ❑ 1 POLYETHLENE WRAP 2TAO OR ASPHALT 3VINYL WRAP /FIBERGLASS REINFORCED PLASTIC <br /> 5 GI-PADTECTgN 91 <br /> ONE 0 95 UNKNOWN <br /> 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE 7SUCTtON A U 3 GRAVUY A U 99 OTHER <br /> B. CONSTpUCTIONLLED A U 2 DOUBLEWALLED A U 3LINEDTRENCH A U 95 UNKNOWNAU W <br /> AN A U 2 STAINLESSSTEEI A U 3 POLYVINL CHLORIDEIPvCI A U < FIBERGLASS PIPE OTHER <br /> C. MATERIAL A A U 6 CONCRETEAED$ILEI A U 95 UNKNOWN A U I STEEL CLAD W/FRP A LA N 100%METHANOL COMPATIBLE FHP <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 5 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR <br /> P S 6 PRECISION TESTING P S I PRESSURE TESTING P S S GROUND WATER MONITORING WELLS <br /> P S 91 NONE P S 95 UNKNOWN <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE P 6 OTHER <br /> I. ESTIMATED DATE LAST USED IMO/YHI <br /> 2 EOF <br /> SUOSIANCE REMAINING IN 3 WAS TANK FILLED WITH <br /> GALLONS INERT MATERIAL' C]YES E] N( <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 IPRINI ED A SIGNP 1 UNF I <br /> DE... <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N <br /> FACILITY IDN TANK 10 N <br /> CUP NT LOCA AGENCY FACILITY IDA '�- <br /> APPROVED BY NAME PNONE N WITH AREA CODE <br /> PER p — -- <br /> T APPpOVAL PATE PERMIT EXPIRATION PATE <br /> CHECK• PERMITAMOUNT -- <br /> SURCHARGEAMT. FEE CODE ' <br /> pECEIPTN BY: <br /> FORM B 13 7.BBI THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FOR M 'A',UNLESS A CURRENT FORM•A' HAS BEEN FILED �� I <br /> a I <br /> DATA PROCESSING COPY <br />