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TANK TAN' 'ERMIT APPLICATION INFORM 'ON <br /> COMPLETE A SEP*,,TE FORM WITH THE FOLLOWING INFORMATIL.�fOR EACH TANK '-',,. <br /> a <br /> [FAClL;lTY/S;lTENAlM;AE <br /> ❑ I NEW PERMIT 3 RENEWAL PERMIT <br /> 5 CHANE OF INFORMATION T PERMANENTLY CLOSED TANK <br /> 2 INTERIM PERMIT Y AMENDED PERMIT ED 6 TEMPORARY TANK CLOSURE E18 TANK REMOVED <br /> WHERE TANK IS INSTALLED: <br /> FARM TANK-YES NO Ej <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY <br /> A. OWNERS TANK 10 N 1 0 <br /> 3 �� KZ B. MANUFACTURED BY: �� <br /> C. YEAR INSTALLED <br /> D. TANK CAPACITY IN GALLONS. C) «� <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(Al),IS NOT MARKED,COMPLETE ITEM D. ? <br /> A. 1 MOTOR VEHICLE FUEL E] 2 PETROLEUMN <br /> B. C.&A UNLEADED 2 LEADED 0 3 DIESEL N <br /> 3 CHEMICAL PRODUCT Ej 1 OIL C "WO �1 GASAHOL 5 JET FUEL 0 6 AVIATION GAS <br /> 5 HAZARDOUS [—]80 EMPTY L]95 UNKNOWN uO 2 WASTE 0 1 METHANOL 0 99 OTHER <br /> D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF (DESCRIBE IN ITEM D.BELOW) <br /> HAZARDOUS SUBSTANCE STORED 8 C.A.S.N <br /> CAS.N <br /> .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B,C,A D <br /> A TYPE OF ❑ 1 DOUBLE WALLED 3 SINGLE WALLED NTH EXTERIOR LINER El 95 UNKNOWN <br /> SYSTEM &'1 SINGLE WALLED 0 A SECONOMYCONTAOMENT O 99 OTHER-- f <br /> B. TANK 2,2 STEELARON 2 STAINLESS STEEL 0 3 FIBERGLASS 0 A STEEL CLAD WIRBERGUSS BENFrncEDPLASPC <br /> MATERIAL 5 CONCRETE 0 6 POLYVIWLOtOF4(E I ALUMINUM 08 10011IME7RANOL COYPATBLE RP <br /> 0 9 BRONZE 0 10 GALVAMZEDSTEE[ 95 UNKNOWN 0 99 OTHER <br /> C. INTERIOR I RIBBERLIWD O 2 ALKYD LINING E]3 EPDXYLINING ❑1 MC40LICLIMNG <br /> LINING ❑5 GLASS LNING UNLINED 1 ❑95 UNKNOWN <br /> ❑ IS LINING MATERAL OOMPATSLF WITH LOB%METIIAl10L, O YES [—]NO E]99 OTHER <br /> D. CORROSION ❑ I POLYETHLENEWRAP ❑2 TARORASPIMLT ❑ 3 VINYL WRAP 1 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ S CAIRMC PROTECTION f C�INGNE El 95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND.BOTH IF APPLICABLE <br /> LI A SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> y B. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A UNKNOVM A U W OTHER <br /> A U I STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U N FIBERGLASSPIPE <br /> C. MATERIAL A U 5ALUMINUM A U 6CONCRETE A U 2STEEL CUD W/FRP A U 81D816 METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZEDSTEEL A 05 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 B I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S < ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS <br /> P B 6 PRECISION TESTING P S ) PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> I. ESTIMATED DATE LAST USED(MO/YR)) 2 ESTIMATED QUANTITY OF 3 WAS TANK EILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL' YES E] NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENAL TV OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED A SIGNATURE I <br /> I / <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY A FACILITY ID 1 TANK ID N <br /> m <br /> CURRENT LOCAL AGENCY FACILITY ID Y APPROVED BY NAME PHONE•WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK PERMIT AMOUNT SURCHARGE ANT. fig CODE RECEIPTY BY: <br /> I <br /> FORM B p-T-ea( THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM W.UNLESS A CURRENT FORMA' NAS BEEN FILED <br /> - _ DATA PROCESSING COPY J <br /> I <br />