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TANK TANK -ERMIT APPLICATION INFORMP ON COMPLETE A SEPA. . E FORM WITH THE FOLLOWING INFORMATIOI )R EACH TANK. MARK ONLY DI NEW PERMIT ❑ 3 RENEWAL PERMIT 1355 CHANGE OF INFORMATION ONE ITEM 0 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE FACILITY/SITE NAME WHERE TANK IS INSTALLED; _ I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN — SO SPECIFY A. OWNERS TANK( Z B. MANUFACTURED BY. C. YEAR INS7 ED 0. TANK CAPACITY IN GALLONS: II T ❑ T PERMANENTLY CLOSED TANK ❑ R TANK REMOVED FARM TANK - YES ❑ NO � I _7 to ANK NENTS IF (A.1). IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM O. A. I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM D. C. ❑ 1 UNLEADED ❑ 2 LEADED DIESEL 3 CHEMICAL PRODUCT ❑ A OIL ❑ I PRODUCT ❑ GASAMOL ❑ 5 JET FI1EL 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ BD EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ T METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW) D. IF NOT MOTOR VEHICLE FUEL. ENTER NAME OF HAZARDOUS SUBSTANCE STORED A. CAS. A CAS. R. .Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN ROY A R c A n A. TYPE OF ❑ ISE WALLED ❑ 3 SINGLE WALLED NRH EXTEROR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 1 SECONDARY CONTAINMENT ❑ 99 OTHER IL TANK ❑ l STEEURON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 1 STEEL CUD W/FIBERGLASS REKIFORCED PLASTIC MATERIAL ❑ 5 OONOETE ❑ 6 PI CELOROF ❑ I ALUMINUM ❑ B (MIL METHANOL COMPATIBLE FRP C. MATERIAL ❑ 9 BRONZE ❑ IO GALVANIZED STEEL ❑ % UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING 3 EPDXY LINING ❑ L PHENOLICUMNG LINING ❑ 5 GLASS LINING ❑ 6 UNUMED 1 f ❑ %UNKNOWN ❑ IS UNNG N ETERAL COMPATIBLE WITH IOD%MERMNOL, 0 YES ❑ NO ❑ 99 OTHER 0. CORROSION ❑ I POLYEIHLENEWRAP ❑ 2 TAR OR ASPIW.T ❑ 3 VINYL WRAP 1 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION 91 NONE ❑ % UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND U IFLINnFR-.Rn1INn V. A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U n OTHER E. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U% OTHER C. MATERIAL A A A U U U I STEEL/IRON 5 ALUMINUM 9 GALVANIZED STEEL A U A U A U 2 STAINLESS STEEL 6 CONCRETE 95 UNKNOWN A A A U 3 POLYVINYL CHLORIDE IPVCI U I STEEL CLAD W/FRP U 99 OTHER A U A FIBERGLASSPIPE A U B I110% METHANOL COMPATIBLE FRP LCmm um P CAI l 1 VPI STS I tM CIRCLE P FOR PRIMARY. OR S FOR SFCnAIn•RV • oeov.ev, �... ..��..�..... _..___.. __..__ __ _._ _. .... P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S A ELECTRONIC MONITOR P 3 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S T PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED GATE UST USED IMO/YRI 2 ESTIMATED OUANTITY OF 3 WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E] YES ❑ NO THIS FORM HAS RFFN CnMPU LOCAL AI r v Int cto 1 Or MY KNOWLEDGE. IS TRUE AND C( APPLICANTS NAME (PRINTED A SIGNA,URF; DIS EI i LITA.1 VAC VPYLr RRECT • COUNTY X X AGENCY R FACILITY ID N �JURISDICTION S9 �. / TANK IDD # •, v CURRENLLQC� GENCY FACILIAPPROVED SY NAME PHONE F WITH AREA CODEvERYIT PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 3CHECK•PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT A BY: LL rvnrvl A. UNLESS A CURRENT FORMA' HASBEENFILED _-- _- DATA PROCESSING COPY A N N j