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TANK TAR' 'ERMIT APPLICATION INFORMMION <br /> COMPLETE A SEF. --,TE FORM WITH THE FOLLOWING INFORMATIVWFOR EACH TANK. *O : <br /> MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED <br /> NK CLOSURE El B TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: 3d � �f�-— <br /> F M TANK-YES 0 NO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY p <br /> F. OWNERS TANK ID N Q B. MANUFACTURED BY. �USCZ) A, <br /> R INSTALLEID -FL 11 <br /> ' R `h1 t�a ,O D. TANK CAPACITY IN GALLONS: 10,006 Cj-AL. <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A <br /> iV <br /> A. t MOTOR VEHICLE FUEL 2 PETROLEUM 7E] <br /> C t UNLEADED 2 LEADED 3 DIESEL N <br /> 3 CHEMICAL PRODUCT 1 OIL RODUCT 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS BO EMPTY 95 UNKNOWN ASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM 0,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED 6 C.A.S.N <br /> C.A.S.N. <br /> XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,8,C.a D ✓ <br /> A. TYPE OF I DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> I STEELPRON 2 STAINLESS STEEL 3 FIBERGLASS STEEL CLAD W/FIBERGLASS RENFORCED PIASTIC <br />>; B. TANK f 5 CONCRETE <br /> MATERIAL 6 POLYVINYL CHLORIDE 7 ALUMINUM B 100%METHANOL COMPATIBLE FRP <br /> 9 BRONZE Ell0 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> C. INTERIOR I RUBBER INED E]2 ALKYD LINING 3 EPDXY LINING g4PHIENOLIC LINING <br /> LINING #IS <br /> LINING a 6 UNLINED I NOWN <br /> ING MATERIAL COMPATIBLE WITH 100%METHANOL? YESNO O HER <br /> D. CORROSIONPOLYETHLENE WRAP 2 TAR OR ASPHALT V WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION [:] 5 CATHODIC PROTECTION 91 NONE 95 NOWN 99 OTHER _. <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUN IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U I SUCTION PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U t SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> A U I STEELPRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A IR)4 FIBERGLASS PIPE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FNP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER <br /> ii V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY.OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br />�1 <br />( ''yrFP <br /> S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS dDS 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> S I PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> I ESTIMATED DATE LAST USED(MO/VR) E2 ESTIMATED QUANTITY OF 3 WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIALS ❑ YES No <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(PRINTED&SIGNATURE) I <br /> DAr.E,•. <br /> LOCAL AGENCY USE ONLY <br /> COUNTY K JURISDICTION N AGENCY N FACILITY 10 N TANK ID N <br /> L 10v l L. 7 -7 <br /> CURRENT LOCAL AGENCY FACILITY 10 a APPROVED BY NAME PHONE 4 WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE DATE <br /> CHECK a PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: <br /> FORM B(3 7-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br /> J <br /> }+�✓9,.c�j g+' 'P..';. f _,va ,ra�i,>M;�.. '.ci.. .._. <br /> .......... <br />