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ATE - <br /> STAIE WATERSOI! CONTROL BOARD sT <br /> UNDERGROUND STORAGE TANK PERMIT.APPLICATION,- a <br /> A R F A S pp "� . <br /> IMM ONLY i NEW PERMIT 3 RENEWAL PERMIT ® 5 PNICOPWATION x PRAMANENTLY CLOSED ONSff.c <br /> ONE ITEM ED 2 IW#ERIM PERMIY ; AMENORO PE04MIT a TEMPORARY TANK CLOSURE, S TAW RE ER <br /> A OR FACILITY MANEE T r—A t— wo 1 = M A <br /> 1. YANK DtSCRIPTIONPLETE ALL ITEMS-8 iFY IF UNKNDWN <br /> A.OWNEWS TAW 1.D.a 8-UANUFACTURED BY. <br /> C, DATE INSTALLED( YIVE I D_TA 'C PTY IN S: �. <br /> II.7 iFA-i iSmAAWD,CAWPLETEITEMC. <br /> i&ACOULAR ; bIESEL 6 AWAT GAS <br /> A. L 1 k4C9TdR VEFIIPLE FUEL 4191E C" UWEA @ <br /> O 2 PETROLEUM ❑ so mprr PREAII 7 METHANOL <br /> � D 5 JET FUEL <br /> Pu 3 c"EMIGAL P.._.___T Q UNKNOWN 2 WASTE 2 LE 6 is OTHER IDEsCRIBE IN EM D.SEL <br /> D. IF th I I IS NOT MARKED,ENTER NAME Of SUBSTANCE CE STORED C_A.S.a <br /> !. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C,AND ALL THAT APPLIES IN BOX D AND E <br /> A. TYPE OF ICOUBLE WALL 3 SI LE WALL WIT}I EXTERR L7795 UNKNOWN <br /> SYSTEM 2 SOMLF WALL 4 SECONDARY CONTAINMENT IVAULTAD TANIq L J99 OTHER_ � - <br /> TANK ! BARE STEEL` 2 STAINLESS STEEL ❑ 9 FIBERGLASS d STEEL MAD WdFIBERGLASS i PLASTC <br /> MArERIAL ® S CONCRETE ® 6 POLYVINYL CHL IDE 7 ALUMMM S t L COMPAIRLE WJFRP <br /> (PriMatV TVIII 11 BRONZE 10 GALVANiZOD STEEL ED as R <br /> I RUBBER LINED 4=s 2 AUKYD LNING a 9 EPDXY LINING Q -11 PHENOLIC LINING <br /> KrERIOP 7 5 GLASS LINING 6'UNLTNED 95 UN O OTHER_, <br /> LINING <br /> iS VNING MATERIAL PATIEILE WITH 1 METHANOL? YES <br /> D.CORROSIDN ® ► POLYETHYLENE WRAP E] 2 TING a VINYL '—FIRE <br /> RGILASS. RE a D TIC <br /> PROTECTION [�] 5 GAT ICP STECTION E3 91 NME �95 UNKNOWN [� So OTHER_ <br /> E.SPALL AND OVERFILL _ SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(Yr ) <br /> PIPING INFORMATION COICLE A 1FASOVEGROUNDOR U IOUNINW.HoUND.BOT,4W-APPLIQAiLLE <br /> A. SYSTEM_TYPE A u I SUCTION �XP SSURE A V S VITY ASI o R <br /> CONSTRU N U I SINGLE WALL E WALL !I 2 LINED TRENCH A 1) k OTHER <br /> C. MATERIAL AND` U I BARE MEL — — A 0 2 STAINLESS STEEL A U ? POLYVINYL CHLORIDE 9 A U a ?1964GLASS PIPE <br /> CORROSION A U 5 ALUMINUM A u ® coNcMTE A U 7 STEEL W COATINGa 1 METHANOL compATiBmwimp <br /> PROTECTION A U B GALI:iANIZED STEEL A U 10 CATMODIOPROTECTION A U G OT"ER ^er <br /> . LEAK DETECTION 7 AUTOMATIC LINE LEDETECTOR ®2 LINE T ES$TOTING fT LNG L�SO OTWER <br /> V.TANK LEADETEMON <br /> 1 VOUAL CHECK 0 ZlIMENTORY RECONCILATONu 3 VAWZE MONITORING 4 AUTOMATIC TANK GAPGM 5 GROUND WATER MONITOAING <br /> B TANK TESTNG. 7 INTERSTITIAL ONNoRiNG Q 91 NONE [� 95 UNKNOWN 20 OTHER <br /> 1.TANK CLOSURE[WORNIATION <br /> I.E3TIL�ATEO DATE 5T u ED(Mp YAPRI 2.ESTIMA ULJANTITY pF 3.WAST K FILLEfl I'ITi YESNO I or I <br /> 56785TAIVCE�IEM�INi S INERT MATEAIAI T <br /> T1fJ t7d�M 3 LEEN�t9 �ZE TED tlfltLlEfT PEATY PERJURY,APY[7 tQ�THET JS (d��4Nl3 RRECT <br /> APPU T&NAME TE <br /> ;P121hTg9 A 9�hATU 1 <br /> LOCAL AGENCY USE ONLYTHE STATE i ,Nu OF THE FOUR NUMBERS ELO <br /> COUNTYO ..XJ ION a FACILfrY# 'TANK S <br /> STATE1.04 <br /> PERMIT NuMuE R PERMIT APPROVED BY TE PERMIT EXPIRA70N DATE <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATIO R A,UHL SACURRENT FORMA HASREPH FILED, <br /> F THIS FO H TH AGENCY PL G T UNDERGROUND S R T REGULATIONS <br /> FORM it(12-Ir) <br /> e <br /> 'd 901OLLZ60Z dVl 1S9hR/8VlS-l-lV HCI HIVES:9 266L-OL-6 <br />