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I HIVK IAc4K PERMIT APPLICATION INFORMATION - <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT <br /> ONE ITEM Q 5 CHANGE OF INFORMATION n I PERMANENTLY CLOSED TANK <br /> 11 21NTERIMPERMIT Ej N AMENDED PERMIT {^�B/ <br /> ❑fiTEMP09Agy TANK CLOSURE TANK REMOVED <br /> FACILITY/BITE NAME WHERE TANK IS INSTALLED � 0 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY C FARM TANK-YESO NO <br /> A OWNERS TANK IDN 1 O <br /> B. MANUFACTURED BY: . _ it <br /> C. YEAR INSTALLED <br /> O. TANK CAPACITY IN GALLONS. <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(Al),IS NOT MARKED,COMPLETE ITEM 0. A <br /> A. MOTOR VEHICLE FUEL 2 PETROLEUM N <br /> B. C. E 1 UNLEADED E]2 LEADED <br /> O CHEMICAL PRODUCT � /OIL DIESEL Tv <br /> I PRODUCT ❑A GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5,HAZARDOUS OBOE MPTY ❑95 UNKNOWN 2 WASTE O 7 METHANOL 99 OTHER)DESCRIBE IN ITEM 0•BELOWI <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 /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,AD <br /> A TYPE Of ❑ IUOLEBLE WALLED J SINGLE WALLED NTH EXYERIOR LINER 95 UN(NOWN <br /> SYSTEM 2SINGLE WALLED 1 SECDNDARYCONTAINMENT 99 OTHER <br /> TANKI STEELIMON 2 STANLESSSIEEL O 3 FIBERGLASS Ej 1 STEEL CLAD WIFIBEWAASS REINFORCED PfASTIC <br /> n B. MATERIAL ❑ 5 El 6 POLYVINYL GNOME 7 ALUMINUM El B 100%METHANOL COMPATIBLE LP9 E 10 GAVANZEDSTEU 95 UNKNOWN 99 OTHER <br /> C. INTERIOR 1 RIBBER LINED 2 AKYOUNING 3 EPDXY UMNG 1 <br /> LINING ❑ 5GLASS LINING 6UMINEO ( 1 P <br /> %UNKNU%MNOW0NNG <br /> N <br /> IS EWING MATERIAL COMPATIBLE WITH 100%METHANOL, YES ONO 99 OTHER <br /> D.CORROSION I POYETMIENE WRAP 2 T 90RASPHMLT 3 VINYL WRAP E:]N FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION E] 5 CATH OOICPROTECTION 91 NOW 95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A If ABOVEGROUND. U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE i A U 3 GRAVITY <br /> _ A U 99 OTHER B.CONSTRUCTION A LA I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U %UNKNOWN A U 99 OTHER <br /> C. MATERIAL <br /> A U I STEEL/IRON A U 2 STAINLESSSTEEI A U 3 POLYVINYL CHLORIDE(PVC) A U A FIBERGLASSPIPE <br /> A U 5 ALUMINUM A U 6 CONCRETE A U I STEEL CLAD W/FRP A U A 10D%METHANOL COMPADOLE FNP <br /> A U 9 GALVANIZED STEEL A U 95 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 /> i <br /> P 5 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S A ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 5 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> I ESTIMATED DATE LAST USED IMO/YRI ESTIMAIEDOUAN111YOF <br /> 3 WAS TANK ERRED WITH <br /> - � SUBSTANCE RfRAINING IN GALLONS INERT MATEflIAL' �YES <br /> .. _ <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(PRINI F D A SIGNA I tIRI I <br /> D/5 <br /> 1 I I' <br /> LOCAL AGENCY USE ONLY <br /> COUNTY MJURISDICTION N AGENCY N FACILITY 10 N <br /> M �_ �_ TANK ID A <br /> � l C� DO `3 <br /> CURRENT AGENCY FACILITY 10 0 APPROVED Br NAME <br /> -. . ._._- � T / ��D PRONEN WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK I PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT 1 <br /> BY: <br /> FORM B 137-B51 THIS FORM MUST BE ACCOMPANIED BY A FACIUTYISITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' NAS BEEN FB.ED <br /> DATA PROCESSING COPY <br /> IBI 400, -.. <br />