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<br /> bI�MPL 'ili'AgiAlhA gild#Wim 1 ii106:L�1WINd iN�6i�1��L 16N V601 EA64 t'ANK- �,4,�. Z
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<br /> IAAOK 6NLVi 4
<br /> `` � IMrrT I? �� i:EilvV�L i'I RNilt ' 5 CHANGE OF INbRfrIATIOiJ ❑7 PERMANENTLY CLOSED TANK
<br /> qNM liEfM"¢ I RI1ui E dull Q 4 AMENbED PERMIT ❑B TEMpO ARYTANI(CLOSURE ❑9 TANK REMOVED
<br /> PACILtFY/Iili liAfwi ,W#iE eE,tAliit Ili i11 tAtLEo (a �{ ,`I_ F CC 04 TANK-YES❑ NO
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<br /> I. TANK��$��i1�TIi5Ff ` �oL .,!f':ALL^If�M 'IF oNkNOWN—Ab$�ECIFY I� f�
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<br /> A: OVVM1IEF%tANlc Ib o # 9. MANUCA)FACTU♦3Ed gY: (� r� ,; t� �,x
<br /> C;YEAR INSfiALLEO ` _ b. TANK CAPACITY IN GALLONS: (
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<br /> I. TANK j �,A; , II`�A i);!A III filf Eft,oOMPLETE ITEIIA�`. P�A j,IS NOT..BiAgKEO COM' ETI;ITfeM d.
<br /> A; 1,IolOTOFi VEHICLE FIfEL, ❑ IYETfibLEL1M 8. C. UNLEADED ❑ 2 LEADED ❑3 DIESEL
<br /> 4 GASAHOL 5 JET FUEL 6 AVIATION GAS
<br /> 3 CNEMICALPI30DUCT 4 OIL-�"'-' � 1 PliODUCT ❑ ❑ ❑
<br /> ❑5 IfAZARDOU ❑$O EI�ISTY ❑95 UIJKNOYYN E—]2 WASTE E]7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW)
<br /> 0. IF NOT MOTION VEHICLE:PUEL,ENTER NAME OF;;
<br /> HA2ARDOU3 3t1k39fiANCE'BTOF�ED A C A i C.A.S.N:
<br /> III. TANK CdN§tftU&ldk MANN 6Nt itk ONLY iN Box A,§i C A o
<br /> ] 4 DOUBLE V/AU E6 ED 15lNGLE WALLED WITH ba RI60 UNER 9S UNKNOM
<br /> TYPE 0 < •❑ z-
<br /> S1ISTEM ❑ SINGLE WALLED M l SECONWN OONTAINMENT . ❑99 OTHER
<br /> SFEELlIRONn
<br /> 2 STAINLESS STEEL ❑ 3 F19ERGLASS ❑ 7 STEEL CLAD W1R6ERGLASS REINFORCED PLAStIC
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<br /> B.TANK ❑s ❑6 ppLYVINYL 61LOMDE NZNkNOWMN
<br /> ❑B ion METHANOL COMPAtIBLE FRP
<br /> MATERIAL F t I�.
<br /> j 8 BRONZE 16 GALVANIZED STEEL 99 OTHER '
<br /> ❑ 1 RUBBER UNER ❑2 ALKYD LINING ❑ 3 EPO%Y LINING ❑4 PHENOLIC LINING
<br /> I C.lw*16I 5 GLASS IJNINf t ❑9 I�IUNED } 10V+N
<br /> i uNlllm; C7 }}
<br /> IS LININGtiIAT'EMALb6MObbLEihtllkiW'%"ANOP! YES NO 99OTiiEfi
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<br /> 11.CORNtl$ION Q 1,ROLYEFHLENE WRAF;',` ❑2 TAR OR ASPHALT ❑3 VINYL ❑ FIBERGLASS REINFORCED PLASTIC
<br /> PROTECTION 5 CATHObtC RRDtEtlbrl ❑9i TONE NkN01vN ❑99 OCHER
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<br /> IV. 01PINd lNt§fi llAflol N F CIF1CLt A IF bf36VE GROUND, Li IF UNbEIiGFIbUN0.BOTli IF APOL�CABLE
<br /> i A Sy"}► A uv..i SUCTION:r A,,U 2 PRESSURE A U 3 GRAVITY I A U. 91 NONE A 5 UNKNO A U 99 OTHER
<br /> 9,COp$TRIInON -U 1„$INtILE 4VALLEtl>;_,: A,.U. 2 DOW c WALLEb A U 3 LINEb TFIEIVCI I A U 9i,NONE 5 UNKNOWN A U 99 OTHER
<br /> A b-.f 5TI EL/IROL1 < A U 2 STAINLESS STEEL A, U 3 POLYVINYLC'LORILIE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE
<br /> C.MATERIAL A Ol 5 ALU1JliNUivl A :U B CONCRETE A U Y S?EEL CLAD.WJFRP A U 9 100%METHANOL COMPATIBLE FRP
<br /> A U 9 GALVAHIzE STEEL AUNKhlO N A U 99 OTHER 13
<br /> s -,K. -
<br /> V. LWIt b9tkdf lbN §Y§TkM' •CIF' tt 0 POR ORIMARY,ON 6 E6;A SECONDAW,A pA 1MAfil LEAK D"EttCTION SYSTEM MUST BE CIRCLED.
<br /> i P I 1 VISUAL CHECK"` II li«, tVEfiuR+llii CVIJCILIAT10N,; A 3 VAOOSE tiAIELLS', $ R .A ELECTRONIC M6NI70R 0 A 5 GROUND WATER MONITORING WELLS
<br /> P 8 ii PRECISION 7E§TING, •. ,pgE9 liE INq,.� :,,i�i, ,, t NONE: P ` .;95 UNKN WN :_ 8 99 OTaER
<br /> VI. INFORfill016N 6N Uklt'r!NMANtNM U666 IN OLACk
<br /> 1. ESTIMATED DATE LAST USED(MOM) }w 2.ESTIMATED OUANTITY OF Iic. 3.WAS TANK FILLED WITH
<br /> 1 UE#STANCE iiEA4AININq tiJ'= r TIN
<br /> MATERIAL? ❑YES ❑NO
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<br /> l� mis Fohm)449� Elv-i✓O1Vj�L I�r 1NI�EFt E1vALTr,OE PER,lI171'I eA�lt7,TO THE BS57 OF x+11'khIOWLE'DGE 1S TRUE AND CORRECT.
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<br /> F#PoLicm&o NAIAE(PRINTE6$BIaNAfiJFtE} Y DATE
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<br /> e6' �til;Illl�i f ` 7 AciENcv €AciLlTti Ib A _ TANK IDo Lblo I? I
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<br /> 9 CURAENT.LOCAL AGIIENCV PACT "ID 1 i A0116VEO BY NAME !� PHONE R WITH AREA CODE
<br /> PERMIT NufI1BEf!, PERMIT A00ROVAL KATE PkhM t EKPIRATiON OAlt
<br /> II CHECK I1PERlNIt AMOUNT -'' BUF1ClIAgq!AMt. Pet!Coft y [HPCCPT A S y+
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<br /> "FORM a(B 29-w THIS FORA MUst BE ACCd[NPAkIE�PA PACIL"1161E APPLICATION, FORM`A'I UNLESS A" ENT FORII'A' HAS BEEN FILED
<br /> DATA Of ddWiNd CO0Y Il
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