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TANK TANK ERMITAPPLICATION 1 FORMA ON s10-" LI COMPLETE A SEPA-,.E FORM WITH THE FOLLOWIN FORMATIO,.._ JR EACH TANK. '".- MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C,L NK ONE ITEM ❑ 2 INTERIMPERMIT ❑ J AMENDEDPERMIT ❑ 6 TEMPORARY TANK CLOSURE 0 TANK REMOVEDIo FACILITYISITE NAME WHERE TANK IS INSTALLED: 410 _ M TANK -YES ❑ NO .. A.aa.nlrlwn COMPLETE ALL ITEMS -IF UNKNOWN—SO SPECIFY I, A. OWNERS TANK ID. B. MANUFACTURED BY, C. YEAR INSTALLED D TANK CAPACITY IN GALLONS TANK NTENTS 0 - -. _-•------�._"-... A. I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM _... �.... .., ..... B. .,ARAOM. A. Acle neMv. C. I TV ❑ 3 CHEMICAL PRODUCT ❑ A OIL I PRODUCT UNL.EAOED fAOED ❑ 3 DIESEL ❑ A GASAHOL 5 N ❑ 5 HAZARDOUS ❑ BD EMPTY ❑ 95 UNKNOWN 2 WASTE JET FUEL ❑ 6 AVIATION GAS ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM 0. BELOW) ❑ 3 FIBERGLASS D. IF NOT MOTOR VEHICLE FUEL. ENTER NAME OF MANTERIAL HAZARDOUS SUBSTANCE STORED & C A.S. K C.AS. B: ❑ 6 POLYVINYLCHLORIDE _111 T'AMM' nn uA•r... ...�. w.. ❑ B IW% METHANOL COMPATIBLE FAP ------- MAR% VNE I TEM ONLY IN BOX A. W C An A TYPE OF ❑ WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UM(NONN SYSTEM 2 SNGLE WALLED ❑ A SECONDARYCONTNNMENT ❑ 99 OTHER S. ❑ I STEELIRON ❑ 2 STNNESS STEEL ❑ 3 FIBERGLASS F]ST A RQMW/RSERCiASSREIMORCEDPIASTIC MANTERIAL ❑ 5 CONOETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ B IW% METHANOL COMPATIBLE FAP ❑ 9 BRONZE ❑ 10 GALVANIZEDSTEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ I RUBBERLINED ❑ 2 ALKYDUMNG ❑ 3 EPDXYLIMNG ❑ 1 PHENOUCLNNG LINING ❑ 5 GLASS LNRC ❑ 6 LINLINED I ❑ 95 LWNOWN U ❑ IS UNING MATERIAL COMPATIBLE WITH IW%METWMILT ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHLEIEWRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ A FIBERGLASS REIFfORCED PLASTIC PROTECTION ❑ 5 CATHOD C PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIP(Y F A V. A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U "OTHER B. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U "OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE IPVQ A U A FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CUD W/FRP A U B IBO%METHANOL COMPATIBLE FRP 3 -9D A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER BY: LIAR Ut TECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY. A PRIMARY LEAK OFTFCTUlM SYSTEM M„Rr RP r,nr, c.. P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S A ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 5 91 NONE P S 95 UNKNOWN P S% OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE LAST USED IMO/VRI 2 ESTIMATED OUANTITY OF 3 WAS TANK EILLEO WITH SUBSTANCE REMAINING IN -- GALLONS INERT MATERIAL) ❑ YES [:]NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PFR.IIIRY AND Tn T"P RFCT nP AAV vun,A.1 cniv to 1�1 11 RRECT APPLICANT "S NAME (PRIMED 6 SIGNAIURF n' LOCAL AGENCY USF ONI Y • COUNTY F N AGENCY M FA/CILIT[Y 11100 N TANK 10 N (�JURISDICTION i// CURRENT LOCAL AGENCY FACILITY 10 F APPROVED BY NAME PRONE F WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXMRATION DATE 3 -9D CNECX F PERMIT AMOUNT SURCHARGE ANY. FEE CODE RECENT N BY: _ - - - • --, ..,... , ...•.. �...., o�..eevMr%mcM OT w r%a.lu nnu a APPLICATION, F V NM -A-, U KESS A CUBNENT FORMA• NAS BEEN FILED DATA PROCESSING COPY