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TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY ❑ I NEW PERMIT Ej 3 RENEWAL PERMIT ` <br /> ONE ITEM El CHANGE OF INFORMATION 07 PERMANENTLY CLOSED TANK <br /> 2 INTERIM PERMIT 0 / AMENDED PERMIT Loj 6 'TEMPORARY�TMKCLOSURE (�B TANK REMOVED <br /> FA ITE NAME WHERE TANK IS INSTALLED:-Ileo O <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IFUNKNOWN- �� FARM TANK-YES NO <br /> SO SPECIFY <br /> 10 <br /> A. OWNERS TANK IDN <br /> B. MANUFACTURED BY: e4 ' <br /> C. YEAR INSTALLED , D. TANK CAPACITY IN GALLONS: <br /> II. TANK CONTENTS IF(A.1),19 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM�D D <br /> �. <br /> A. ® I MOTOR VEHICLE FUEL Ej 2 PETROLEUM <br /> 3 CHEMICAL PRODUCTEj �I UNLEADED Lj 2 LEADED Ej 3 DIESEL CD <br /> 1 OIL Vp I PRODUCT /GASAHOL El 5 JET FUEL E]6 AVIATION GAS N <br /> 5 HAZARDOUS El BO EMPTY O 95 UNKNOWN EJ 2 WASTE )METHANOL El 99 OTHER(DESCRIBE IN ITEM D.BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.N <br /> C.A.S.M. <br /> Kill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B.C.&D <br /> A TYPE OF L,Jl DOUBLE WALLED 3 SINGLE WALLED MTH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM El 2 SINGLE WALLED 1 SECONDARY CONTAINMENT El 99 OTHER <br /> e B. TANK &-I STEEL/MON 0 2 STAINLESS STEEL 0 3 FIBERGLASS E]/STEEL CUD W/RBE%UM RENFORCED PLASTIC <br /> MATERIAL ❑5 CONCIETE 6 POLYVINYL CELORDE 0 )ALUMINUM O B 100%METHN/OL COMPATIBLE FRP <br /> 9 BRONZE 10 GALYUMZED STEEL O 95 UNKNOWN 0 99 OTHER <br /> C. INTERIOR I RUBBERLNED 2 ALKYOLNING E] 3 EPDXY LINING F-1 1 PHENOLICUNING <br /> LINING ❑6 GLASS LINING ®.6 UNLINED I F]95 UNKNOWN 1 <br /> IS ENING MATERIAL COMPATIBLE WITH 100%METHANOL, YES ONO El99 OTHER <br /> D. CORROSION I POLYETHLENEWRAP 2 TAR OR ASPWT 3VNYL WRAP 1 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION f-'-1 5 CATHODIC PROTECTION E]91 NONE 95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A SYSTEM TYPE A SUCTION A U ?PRESSURE A U 3 GRAVITY <br /> f A U 99 OTHER <br /> 11 B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A UNKNOWN A U 99 OTHER <br /> A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U I FIBERGLASS PIPE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U I STEEL CLAD W/FRP <br /> A U 8100%MEiHANOL COMPATIBLE FNP <br /> A U 9GAlVANIZED STEEL A095 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY.OR S FOR SECONDARY.A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S I ELECTRONIC MONITOR ■ S S GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S ) PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S %OTHER MVC <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> I ESiIMgTEO DATE LAST USED IMO/YR) 2 ESTIMATED QUANTITY OF 3 WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL 1 1:1YES D 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 A SIGNATURF 1 OTT E 1 <br /> 1 / ' <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION N AGENCY F FACILITY ID F TANK ID N <br /> CURRENT LOCAL AGENCY FACILITY LD A LDATV <br /> Y NAME PHONE F WITH AREA CODE <br /> PERMIT NUMBER LlUlC-AllE <br /> PERMIT <br /> EXPIRATION DATE - <br /> CHECK N PERMIT AMOUNT CODERECEIPT N BY: <br /> FORM B 13-)SBI THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM W.UNLESS A CURRENT FORMA' MAS BEEN FILED <br /> DATA PROCESSING COPY <br />