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TANK TANK HERMIT APPLICATION IN RMP'ION COMPLETE A SEPA. FORM WITH THE FOLLOWIN FORMATIY„�OR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT E�fS CHANGE OF INFORMATION ❑ 2 PERMANENTLY CLOSED TAN ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED:OFF G ARM TANK - YES ❑ NO ❑ '7 I. TANK DESCRIPTION COMPLETE ALL ITEMS -IF UNKNOWN — SO SPECIFY o A. OWNERS TANK 10 E B. MANUFACTURED BY: C. YEAR INSTALLED 10. TANK CAPAC4TY IN GALLONS: II. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. ? N A. ❑ I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. 1 ,/ C. ❑ I UNLEADED ❑ 2 LEADED 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL I PRODl1CT ❑ 4 GASAHOL ❑ 5 JET FUEL N ❑ fi AVIATION GA$ ❑ 5 HAZARDOUS ❑ M EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ I METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D. BE D. IF NOT MOTOR VEHICLE FUEL. ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 C A.S. M C.A S. N: .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A. B. C- A n A TYPE OF ❑ I DOUBLE WALLED 3 SINGLE WALLED NTH EXTERIOR LINER F-195 UNMOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER B. TANK ❑ i STEEUMION ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STERE CLADWIFIBERCAASS REOFONID FUSTIC MATERIAL ❑ 5 CONCflEiE ❑ 6 POLYVINYL CHLORIDE E]I ALUMINILM ❑ B 10011METHANOL COMPATIBLE FRP ❑ 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNMOWN ❑ 99 OTHER C. INTERIOR F -]i RLEKRLINED ❑ 2 AUDDLINING El 3 EPOWUNING ❑ 4 RENOLICLMNNG LINING ❑ 5 GLASS LINING ❑ 6 UNLINED 1 ❑ 95 UNKNOW! A ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL, YES ❑ NO ❑ 99 OTHER 0. CORROSION ❑ 1 POLYETHHE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED MASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 N NE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION rlRr. CA IC AM ,.c r V. A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 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 ISTEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U I STEEL CA—ADW/FRP A U 8 1(X31 METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER LtAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE rUmm Pn P S I VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 5 6 PRECISION TESTING P S Z PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S W OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I ESTIMATED DATE LAST USED IMOKYR) 2 ESTIMATED OUANTITY OF 3 WAS TANK FILLED WIT. SUBSTANCE REMAINING IN GALLONS INERT MATERIAL' ❑ YES [:]NO 11131 •••• • •• -•��• • ....., �� . �.. v,•,acn �uvnc r r Ur rcn✓Un T, ANU IU I HE tlES I OF MY KNOWLEDGE. IS TRUE AND C APPLICANT'S NAME IPRINTM 6 SIGNATIIRF I D15 EI b� TRECT '-VA.AL ALAtINL.T U5t UNLY • COUNTY M JURISDICTION N AGENCY N FACILITY ID N TANK ID N 1�lij =- / 1 CURRENT LO AL AGENCY FACILITY ID A - - APPROVED BY NAME PHONE M WITH AREA CODE NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE /f -! I PFewIT AMOUNT SURCHARGE AMT. FEE CODE RECOPTN BY� rMHMDlr1-LWI INwrvHMMU51 Bt AEI:UMPANIEU BY AFAULITY/SITE APPLICATION, hUHM'A', UNLESS A CURRENT FORMA HASBEENFILEO DATA PROCESSING COPY