BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

TANK TAS'.. PERMIT APPLICATION INFOR? TION COMPLETE A SL .ATE FORM WITH THE FOLLOWING INFORMA YII� FOR EACH TANK. ... . MARK ONLY ❑ 1 NEW PERIAIT ❑ 3 RENEWAL PERMIT ONE ITEM ❑5 CHANGE OF INFORMATION ❑ 1 PERMANENTLY CLOSED TANK ❑21NTEflIM PERMIT ❑1 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE0 B TANK REMOVED FACILITY/BITE NAME WHERE TANK IS INSTALLED: 1. TANK DESCRIPTION COMPLETE ALL ITEMS•IF UNKNOWN—SO SPECIFY FARM TANK•YES❑ NO ❑ A. OWNERS TANK IDM to B. MANUFACTURED BY: C. YEAR INSTALLED Yl '< 2. T Y7 D. TANK CAPACITY IN GALLONS: S II. TANK CONTENTS IF(A.1g IS MARKED,COMPLETEfs ITEM C.IF(A 1),IS NOT MARKED,COMPLETE ITEM D, Cl. A' P!�_l MOTOR VEHICLE FUEL ❑2 PETROLEUMiV ❑3 CHEMICAL PRODUCT ❑1 OIL B C. ❑ 1 UNLEADED E:]2 LEADED ❑ 3 DIESEL N ❑ I PRODUCT ❑1 GASAHOL ❑5 JET FUEL 6 AVIATION GAS ❑ 5 HAZARDOUS ❑eD EMPTY F-]95 UNKNOWN .fac 2 WASTE O T METHANOL ❑99 OTHER(OESCRIBE IN ITEM O,RELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 C.A.S.N All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,A D A TYPE OF KI DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LDER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED 1 SECONDARY CONTAINMENT 0 99 OTHER ❑ B I STEEL/MON ❑2STAINLESS STEEL �FIBERGUSS ❑4SIM CUD W/FIBERGLASS REWORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYL CHLOROE ❑ 1 ALUMINUM ❑%IOD%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑1 PWNOLCUMIIG LINING ❑ 5 GLASS LMIM'', fA 6 UNLINED I ❑%UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IOD%METHANOL, El YES 0 N 99 OTHER D.CORROSION ❑ 1 POLYETHLEIE WRAP ❑2 TAR OR ASPBALT ❑3 VINYL WRAP ❑1 FIBERGLASS REIMORCED RAM PROTECTION ❑ 5 CATHODIC PROTECTION '15�1 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNOERGROUNO,BOTH IF APPLICABLE A SYSTEM TYPEA U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U I SINGLE WALLED A-tp j DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U I STEELRRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE PVC) A U 4 FIRERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U ) STEEL CUD WIFRP A U 6 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A V UNKNOWN A U 99 OTHER a 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 P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S < ELECTRONIC MONITOR P g 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S ] PRESSURE IESTING P S 91 NONE P S 95 UNKNOWN r99 OTHER 59 Sp r VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I ESTIMATEOO Et , USED(MO/YR) 2 ESTIMATED OUANTOY OF 3 WAS TANK FILLEDWITH G SUBSTANCE REMAINING IN INERT MATERIAL' ❑YES [:] NOU GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE ANO CORRECT APPLICANTSNAME(PRINTEDASIGNATURE) OAAI LOCAL AGENCY USE ONLY COUNTY P JURISDICTION N AGENCY N FACILITY ID N TANK ID P m CURRENT LOCAL AGENCY FACILITY 10 P APPROVED BY NAME PHONE I WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE BEpM1T ERPMATN)N DATE CHECK P PERMIT AMOUNT SURCHMOE AMT. FEE CODE RECEIPT P BY: I FORM B(3-''m) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPUCATION, FORM W.UNLESS A CURREM FORMA' HAS BEEN FILED 0ATA PROCESSING COPY j