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ANS( LAI'"' PERMIT APPLICATION INFOR. - ''ION COMPLETE A SE. I,TE FORM WITH THE FOLLOWING FORMA7_ FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT d ONE ITEM 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE K REMOVED O FACILITY/SITE NAME WHERE TANK IS INSTALLED: ❑8 TAN FARM TANK-YES❑ NO ❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY '7 A. OWNERS TANK ID N Q� f I EB. MAN7UFACTURED BY:C. YEAR INSTALLED TY IN GALLONS: 2 ZQO II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A A. ❑ I OTOR VEHICLE FUEL ❑2 PETROLEUM B. C ❑ I UNLEADED 2 LEADED 3 CHEMICAL PRODUCT ❑ 4 OIL ❑3 DIESEL N 1 PRODUCT ❑1 GASAHOL JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 1 METHANOL OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.N C.A.S.a ,(III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a o A. TYPE OF ❑ I DOUBLE MULLED ❑ 3 SINGLE WALLED NTH EXTERIOR LINER ❑9s UNKNOWN SYSTEM ffj_2 SINGLEWALLED 1:14 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/IRON B ❑ 2 STAINLESSSTEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MANTERIAL E] 5 CONCRETE 1:1 El 6 POLYVINYL CHLORIDE 7 A ❑ ❑B 10011 METHANOL COMPATIBLE FRP El 9 BRONZE ❑ 10 GALVANIZED STEE1 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LININ(; F-13 EPDXY LINING PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINED 1 I M%UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOLS ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ I POLYECATHODIC HLENE WRAP ❑ 2 TAR OR ASPHALT I� 41NYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE llllu/I 995 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLL A If ABOVE GROUND, U If UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PHLSSUHE A U 3 G14AVIIY A 99 OTHE B. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH ---- 95 UNKNOWN A U 99 OTHER 1 STEEL/IRON A U ? STAINLESS S1 f EI A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A LI 1 STEEL CLAD W/FNP A U R 100%METHANOL COMPAIIHLE FHP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. PUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I ESTIMATED DATE LAST USED(MO/YHA - - -- - -__ _ ESIIMA7 FD ODANTIIY OF 9 WAS TANK FILLED WITH SUIVJANCE REMAINING IN INERT MATERIAL" GALLONS El YE S 0 NO THIS FORM HAS BEEN COMPLETED UNDER PENAL TY Ol PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT APPLICANT'S NAMF(PRIM f �SIGNn IUNI I OA f!•. LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY* FACILITY IDN Em 3TANK ID N � o I f 7 -7. '. CURRENT LOCAL AGENCY FACILITY ID r - APPROVED BY NAME PHONE r WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE L CHECKS PERMIT AMOUNT ---- 11��a SURCHARGE AMT. FEE CODE RECEIPT r BY:r FORM B(3.7-Ile) T IS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A', DATA PROCESSING COPY UNLESS A CURRENT FORM'A' HAS BEEN FILED --- ----- --- ^ i ��, �5.`I'�.a!q'.��il::.;,.:F:Y'isoi !ii�iilff. .lSitY..tlL'iLL1P_!`:i: :i: :.«:SK::u:n:r•. �..;.::,.-:.,. .-.�..... ._. ... ..