BILLING PRE 2019 - Laserfiche WebLink

Home Browse Search

I AN K I ANO' PERMIT APPLICATION INFORRWION COMPLETE A SE. ITE FORM WITH THE FOLLOWING IN.ARMA FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑�RENEWAL PERMIT ONE ITEM 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED TANK ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED O r FACILITY/SITE NAME WHERE TANK IS INSTALLED: fry- 7Q 1 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY �� FARM TANK-YES❑ NO A. OWNERS TANK IDM d I O B. MANUFACTURED BY: /r��t� C. YEAR INSTALLED R� (4 o D. TANK CAPACITY IN GALLONS: �p��jQU &14-L� =��] II. TANK CO TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,C A A. I MOTOR VEHICLE FUEL E] B 2 PETROLEUM COMPLETE ITEM D. B. C I UNLEADED ❑2 LEADED ❑ J CHEMICAL PRODUCT E] 4 OIL ❑3 DIESEL N I Pfl000Ci ElGASAHOL ❑5 JET FUEL ID 6 AVIATION GAS ❑ 5 HAZARDOUS El 80 EMPTY El 95 UNKNOWN ❑2 WASTE ❑ 1 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 C.A.S.a MI. C.A.S.p I. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.8,C,8 D A. TYPE OF I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑B 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS 4 STEEL CLAD W/RBEFIGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZEDSTEEi ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR 1 RUBBER LINED ❑ 2 ALKYD LINING F-13 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑ 5 LINING ❑6 UNLINED 1 ❑%UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 10091 METHANOL-, ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALTW95 NYL WRAP ❑/FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A If ABOVE GROUND. U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSETYPEA U 1 SUCTION A 2 PRESSURE A U 3 GHAViTY A U 99 OTHER B. CONU I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER U I STEEL/IRON A U STAINLESS S.1I A U 3 POLYVINYL CHLORIDE(PVC) A �4 FIBERGLASS PIPE C. MATU 5 ALUMINUM A U 6 CONCRETE A U ! $TEFL CLAD W/FHP U ) GALVANIZED STLEL A U 95 UNKNOWN , A U B 10091 METHANOL COMPATIBLE FHP A U 39 OTHER 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 HL CONCILIA T ION P S 3 VADOSE WELLS OS 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS ;{•�(�L/ 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 1 ESTIMATED DATE LAST USED(MO/YHI - ----O ----- __ _ ESTIMATED 3 WAS TANK FILLED WITH � S11BtiIANC[ fit I'HAWAININGG IN INERT MATERIAL'S GALLONS ❑YES ❑ NO� THIS FORM HAS BEEN COMPLETED UNDER PENALTY 07 PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT APPLICANT'S NAMF(PRIM IFI,{SIGNA 1 uHi I Ori E I.. LOCAL AGENCY USE ONLY COUNTY M JURISDICTION K AGENCY N EEI FACILITY ID N ITANK CURRENT LOCAL AGENCY FACILITY.. E=- 504-1 APPROVED BY NAME PHONE PERMITNUMBER PERMIT APPROVAL DATE PERM17 EXPIRATION DATE T SURCHARGE AMT. FEE CODE RECEIPT• FORM B 13.7-BBI THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' NAS BEEN FILED ----- ---- .-- DATA PROCESSING COPY _. ,.-/