BILLING - Laserfiche WebLink

Home Browse Search

TANK TANK 'ERMITAPPLICATION INFORMA 7N COMPLETE A SEPAh► 'E FORM WITH THE FOLLOWING INFORMATlotfVbR EACH TANK. - MARK ONLY ❑ i NE RMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 2 PERMANENTLY CLOSED TANK ONE ITEM INTERIM PERMIT A AMENDED PERMIT 6 TEMPORARY TANK CLOSURE B TANK REMOVED /Q FACILITY/SITE NAME WHERE TANK IS INSTALLED: /�.y FARM TANK-YES❑ NO _7 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY I O A. OWNERS TANK IDN B. MANUFACTURED BY: C. YEAR INSTALLED I O. TANK CAPACITY IN GALLONS: A II. TANK CONTENTS If(Al),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A_ n I MOTOR VEHICLE FUEL 2 PETROLEUM B. C. 1 UNLEADED 2 LEADER 3 DIESEL 3 CHEMICAL PRODUCT A OIL 1 PRODUCT 4 GASAHOL 5 JET FUEL ❑6 AVIATION GAS N 0 5 HAZARDOUS 90 EMPTY [-]95 UNKNOWN 2 WASTE ❑ T METHANOL 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 CA S.N GA N: =III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A.B,C,AD A TYPE OF ❑ I DOW WALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM 2 SINGLE WALLED A SECONDARY CONTAINMENT Ej 99 OTHER I STEEURON 2STAINLESS STEEL ❑ 3FIBERGLASS 1STEEL CUDW/FIBERGLASS REINFORCED MASTIC S.TANK 5 CONCRETE E]6 POLYVINYL CH DROF F-1 I ALUMINUM 8 IOD%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE IO GALVANIZED STEEL El 95 UNKNOWN 99 OTHER C.INTERIOR ❑ I RIBBER LINED 2 ALKYD LINING I F-1 3 EPDXY LINING 1 PENOLN;UMNG LINING ❑5 GLASS LINING F-1 fi LAMMED 195 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 1005 METHANOL' 0 YES E] NO ❑ 99 OTHER D. CORROSION ❑ I POLYETMEM WRAP 0 2 TARORASPHALT F-1 3VIWL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALLED A U 2 OCUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS STEEI. A U 3 POLYVINYL CHLORIDE(PVC) A U A FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 2 STEEL CLAD W/FRP A U B 14IO%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STFEL. A U 95 UNKNOWN A U "OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY.OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. PS I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VAOOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P 5 6 PRECISION TESTING P S 2 PRESSURE IFSTRIG P S 91 NONE P 5 95 UNKNOWN P S W OTHER Vi. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE T ESTIMATED DATE EAST USED IMO/YRI Z ESTIMATED QUANTITY Of 3 WAS TANK FILLED WITH $UBSIANCE REMAINING IN GALLONS INERT MATERIAL' YES 0 NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT APPLICANT S NAME(PAINTED 6 SIGNATURE I DA EI, LOCAL AGENCY USE ONLY CCOOUU�NTY/N II JURIIS�DICTI'ON N II AIG�ENCYf N FACILITY 10 N TANK 10 N LU CURRENT LOCAL AGENC�D�� APPROVED BY NAME ONE F WITH AREA CODE PERMIT NUMBER PERMIT APMOVAL DATE RMIT ATION D CHECK A PERMIT AMOUNT SURCHARGE AYT. FEE CODE RECEIPT• BY: FORM B L3 1-BBI THIS FORM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FORM W,UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY s �B►