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I AIV K I ANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK, ' <br /> MARK ONLY ❑ I NEW PERMIT 7:FWWWAL PERMIT <br /> ONE ITEM S CHANGE OF INFORMATION I PERMANENTLY CLOSED TANK <br /> 2INTERIM PET MIT D1 AMENDEDPEWIT E06 TEMPORARY TAW CLOSURE <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: � L� TAI'IK REMOVED /I <br /> I. TANKOESCRIPTION COMPLETE ALL ITEMS.IF UNKNOWN—SO PECIFY FARM TANK-YES I/O <br /> A OWNERS TANK ID N to <br /> 8. MANUFACTURED BY: <br /> C. YEAR INSTALLED L� `�•"�'"��.. <br /> D. TANK CAPACITY IN GALLONS: <br /> 11. TANK C TENTS IF ),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED, PLETE ITEM D. <br /> A <br /> A <br /> MOTOR VEHICLE FUEL (A1 <br /> �2PETROLEUM N <br /> B' C I UNLEADED Q 2 LEADED D DIESEL <br /> ❑J CHEMICAL PRODUCT �/pg TILL-y�JO}^/ N <br /> 5 HAZARDOUS BD EMPTY 0 95 UNKNOWN PROOl1CT O A GASAHOL 5'�FUEL ❑6 AVIATION GAS <br /> D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF 2 WASTE D T METHANOL D 99 OTHER(DESCRIBE IN ITEM D.BELOW) <br /> HAZARDOUS SUBSTANCES GRED 6 C.A.S.N <br /> x111. TANK CONSTRU TION MARK ONE ITEM ONLY IN BOX A.B,C.a D CAS.N <br /> A TYPE OF ❑ I Ocu ETV 7 SINGLE WALLED MTR EXTERIOR EWER <br /> SYSTEMEl95 UwHOW N <br /> 2 SINGLE WADE 1 SECONDARYCONTAINMENT <br /> 99 OTHER <br /> B.TANK ❑ I STEEL/MON D 2 STAINLESS STEEL 7 FBEgDIA$S <br /> 1 STEEL CLAD W/FIBERCA,L9SREYfOpCEDPIASTIC <br />'.' MATERIAL ❑ S CONUF"ZE E 6 POLYVINYL CHLORIDE 7 ALUMINA <br /> BRONZE <br /> 9 D B 100%METHANOL COMPATIBLE FLIP <br /> Ia GuvAMZED STELE D 95 UNKNDWN El 99 OTHER <br /> C. INTERIOR 01 RUBBERLINOD 2ALKYDUNING 1:13EPOKYUNING 1 <br /> LINING ❑5 GLASS LINING PLNNNG <br /> 6 OPINED 1 1 �%OY(NONWNDWN <br /> 0 IS LINING MATEFW COMPAHBL MIR 100%METHANOL i ❑YES DNO 99 OTHER <br /> D. CORROSION 01 POLYETHLENEWRAP TARORASRMLT _- 03 VWYIE WRAP I FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION O 5 CATHODIC PROTECTION El 9 NONE <br /> 95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IFAB VE GROUND, U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A SYSTEM TYPE A U I SUCTION A U PRESSURE <br /> A U ]GRAVITY A U "OTHER <br /> B.CONSTIIUCTION A U I SINGLE WALLED A U 2 BLE WALLED A U ]LINED TRENCH A U 95 UNKNOWN A U 99 DIRER <br /> A U 1STEEL/IRON A U ) S INlESS 9IFE1 A U ]POLYVINYL CHLORIDE LPVCI A U A FIBERGLASSPIPf <br /> C. MATERIAL A U 5 ALUMINUM A U 6 RETE <br /> A U ) STEEL CUD W/FRP A U R IW%METHANOL COMPATIBLE FHP <br /> A U 9 GALVANIZED STEEL A U 95 UN OWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PHIMAR OR S FOR SECONDARY.A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P 3 1 VISUAL CHECK P S 2 1NVENTOW RECONC#LIATION P S VADOSE WELLS P S < ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S I PRESSURE TESTING <br /> P S 91 HE P S 95 UNKNOWN P g 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSE IN PLACE <br /> :7777=—ESTIMATED DATE LAST USED IMO/PRI _ <br /> 2 ESTIMATED O I1Y OF ] WAS TANK fILLED WITH <br /> SUBSIAN('.E RFMA BNG IN INERT MATERIALI <br /> GALLONS YES NCI <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJUR AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED ft SIGNn IIniF 1 <br /> Oq f!-. <br /> LOCAL AGENCY USE ONLY , <br /> COUNTY N JURISDICTION N AGENCY N FACILITY ID N <br /> TANK ID N <br /> CURRENT LOCAL AGENCY FACILITY 10 x <br /> ^ ) ^ APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER /L/! 5 -- pERMrt wPppOYAI DATE �� -- - -- <br /> PERMIT EMNATION DATE <br /> (� CHECK F PERMIT AMOUNT SUR­C RANGE AMT. <br /> FEE CODE RECEIPT E <br /> BY: <br /> \ FORM019d•811I THIS FORM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FORM 'A.UNLESS A CURRENT FORM'A' HASBEENFILED - <br /> -- ------- .-. DATA PROCESSING COPY <br /> .i <br />