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TANK TANK SRMIT APPLICATION INFORMA :)N <br /> COMPLETE A SEPARNFFE FORM WITH THE FOLLOWING INFORMATIOWOR EACH TANK. <br /> MARK ONLY ❑ I�PERMIT F-1 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM 2INTERIM PERMIT El M AMENDEDPERMIT 6 TEMPORARY TANK CLOSURE B TANK REMOVED O <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: 41�99 <br /> FARM TANK-YES NO _7 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 10 <br /> A. OWNERS TANK IDN R. MANUFACTURED BY: <br /> I C. YEAR INSTALLED I O. TANK CAPACITY IN GALLONS: <br /> A <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. (V <br /> A_ F-] I MOTOR VEHICLE FUEL 2 PETROLEUM e. C. 1 UNLEADED 2 LEADED 3 DIESEL N <br /> ❑ 3 CHEMICAL PRODUCT 1 OIL I PRODUCT M GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> El 5 HAZARDOUS NO EMPTY [-]95 UNKNOWN 2 WASTE 7 METHANOL 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 C.A.S. <br /> .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.8 D <br /> A TYPE OF ❑ I DOUBLE WALLED F-] 3 SINGLE WALLED WITH EXTERIOR LINER 95UNKNOWN <br /> SYSTEM E]2 SINGLE WALLED E14 SECONDARY CONTAINMENT S OTHER <br /> I STEEL/NDN El 1 STAINLESS STEEL ❑ 3FIBERGLASS 1STEEL CLAD INNIBERGLAISS REINFORCED PLASTIC <br /> B. TANK F-1 5 CONCRETE 6 POLYW DL MOM f-I 7 ALUMINUM 6 100%METHANOL COMPATIBLE RIP <br /> ` MATERIAL <br /> 9 BRONZE 10 GALVANIZED STEEL El 95 UNKNOWN 99 OTHER <br /> C.INTEWOR ❑ I RIBBER LINED 2 ALKYD LINING F-] 3 EPDXY LINING Ej 1 PHENOLICUMNG <br /> LINING ❑ 5 GLASS LINING 6 UNLINED I F1 95 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL' EIYES E]NO O 99 OTHER <br /> D. CORROSION ❑ 1 POLYETHLEIEWRAP 2TAR OR ASPHALT D3VINYL WRAP ❑A FIBFRGLAS$REINFORCED PLASTIC <br /> PROTECTION El 5 CATHODIC PROTECTION 91 NONE El 95 UNKNOWN El 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IFABOVEGROUNO. U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U "OTHER <br /> B. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> A U I STEELPRON A U 2 STAINLESS STEEL. A U 3 POLYVINYL CHLORIOE(PVC) A U A FIBERGLASS PIPE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B IppW METHANOL COMPATIBLE FRP <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 /> P S IVISUAL CHECK P 5 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S A ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS <br /> P 5 6 PRECISION TESTING P S 7 PRESSURE TESTING P 5 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> I. ESTIMATED DATE LAST USED IMO/YRI 2 ESTIMATED QUANTITY OF 3 WAS TANK EILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIALP Ej YES Cj NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENAL TY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED S SIGNATURFI UI(EI <br /> 1 � <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK IO N <br /> CURRENT LOCAL AGENCY FAC141TT�ID�� APPROVED BY NAME PHONE N WITH AREA CODE <br /> 45 <br /> PERMIT NUMBER PERMIT APPRt!!4 <br /> R %DATE <br /> CNECK• ►ERMIT AMOUNTSURCHARGE AMT. RECEIPT N BY: <br /> FORM B 0 7dM) THIS FORM MUST I E ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM W.UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br /> �P w� <br />