BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

I AIV K 'At" PEEWIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK � a MARK ONLY ❑ 1 NEW PERMIT 1_44 ONE ITEM ❑3 RENEWAL PERMIT ❑5 CHARGE OF INFORMATION ❑2 INTERIM PERMIT ❑N AMENDED PERMIT Zp:P87 ANENTLY CLOSED T FACILITY/SITE NAME WHERE TANK IS INSTALLED; ❑6 TEMPORARY TANK CLOSUREREMOVED L TANK DESCRIPTION COMPLETE ALL ITEMS•IF UNKNOWN—80 SPECIFY -YES❑ NO A OWNERS TANK IDN I I O B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: A. I MO 11. TANK C TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM DR VEHICLE FUEL 1:3 .2 PETROLEUM A TO N ❑3 CHEMICAL PRODUCT ❑AOR B C. ❑ 1 UNLEADED ROLLEADED ❑J DIESEL ❑5 HAZARDOUS ❑BD EMPTY 95 UNKNOWN �N UCT ❑N�� ❑5 JET FUEL ❑6 AVIATION GAS N ❑ ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 C.A.S.N .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B.C.i D CAS.N. A TYPE ❑ WALLED El 35EMdE WALLED NTH FXTEPoIXi LINER [:]95 INIKNOWN SYSTEM STEM 2 Al1ED ❑4 SECONOMYCONTANIMENTEj W OTHER i S.TANK I STEEUMON ❑2 STMNLESSSREL ❑3 FSERGUSS ❑1 STEEL CUD WIFEIERGIASSREINFORCED MATERIAL ❑5 CONCRETE ❑6 PoLYVINR CILCROF ❑ 7 ALUMINUM [_19 BRONZE ❑ 10 GALVAMZED STEEI ❑95 UNKNOWN O 99 OTHER 8 100% Ef11M1OL COAIPA7IBU FRP PLASTIC C.INTERIOR ❑ 1 TOWERLINED ❑2 gIXY - ❑3 EPDXY LIN` ❑1 RIENOLICLIMNG LINING ❑5 GLASS LINING UNLINED 1 I ❑95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WTH 100W METRANOIT ES �NO ❑99 OTHER D.CORROSION ❑ I POLYETRUNFNEAP ❑2 T ASPHALT ❑ 3 VINYL WRAP ❑I FIIERGIASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUNU. U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U SUCTNkN A U 2 PRESSURE w U l GRAVITY A U 99 OTHER B. CONSTRUCTION A SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A y 95 UNKNOWN A U STEEL/IRON A U 2 STAINLESSSIEFI A U 3POLWINYL CHLORIDE IPV CI A U AFIBERGLASSppE A 11 99 OTHER C. MATERIAL A U 5 ALUMINUM A U 6 CONLREIf A U I OTHER W/FNP A U B IWILMEMANOL COMPA718LE FRP A U 9 GALVANIZED SILEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUAL CHECK • S 2 INVENTORY RECONCILIATION P S LLS P S A ELECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S I PRESSURE TESTING S 91 NONE P S 95 UNKNOWN P S "OTHER VI. INFORMATION ON TANK PERMANENTL15ZY CLOSED IN PLACE I ESTIMATED GATE LAST USED`MO/YHI - - ? ESSS7ANC O REMAINING I 3 WAS SARK EILLED WITH SURSigNCE HPMAINING IN INERT MATERIAL( GALLONS ❑YES ❑ND� THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,ANO TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME EPHINIFD A SIGNA(UHT D�E!•. 1 LOCAL AGENCY USE ONLY •� �COOU�NT/Y N JURISDICTION N AGENCY N FACILITY ID A TANK ID N CURRENT AGENCY FACILITY W E --- APPROV B AME (� HANE N WITH AREA COOE PERMIT NUMBER - - P ERMITPPROVAL A PERMIT EXPIRATION DATE CNECNF PERMIT AMOUNT . ---- - _ --- -- FEE CODE RECEIPT N ec FOIWI B 13.7-88I THIS FORM MUS T BE ACCOMPANIED BY A FACILETY/SITE APPLICATION, FORM W.UNLESSACURRENT FORY'A' HAS BEEN FILED I ----- -- .-- DATA PROCESSING COPY .1a35.ytCiXC6!i:; ii:l_ :c'as+7lBrrtii,;:.,,