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I ANK I AIVK PERMIT APPLICATION INFORMP-90N COMPLETE A SEP r \TE FORM WITH THE FOLLOWING INFORMATI ,-OR EACH TANK. a 2 INTERIM PERMIT MARK ONLY ❑ I NEWPERMIT J RENEWAL PE MIT � ONE ITEM 05 CHANGE OF INFORMATION`) ❑ T PERMANENTLY CLOSED TANK AAEENOEDPERMIT 11 6 TEMPORARY TANK FACILITY/SITE NAME WHERE TANK IS INSTALLED: ) CLOSURE El TANK REMOVED F:Iloe I. TANK DESCRIPTION COMPLEF AqM TANK YES TE ALL ITEMS IF UNKNOWN— ❑ NO ❑ _> SO SPECIFY 'O t A OWNERS TANK IDI 6 C. YEAR INSTALLED S. MANUFACTURED BY: (J U K. D. TANK CAPACITY IN GALLONS; COQ G 11. TANK CONTENTS IF(A1),IS MARKED.COMPLETE ITEM C.IF(A.1),IS NOT MARKED.COMPLETE ITEM D. A A. ❑ 1 MOTO;VVEHICLE FUEL ❑2 PETROLEUM 9 C. ❑ 1 UNLEADED ❑2 LEADED ❑7 DIESEL ❑7 CHEMRpOUCT ❑K OIL ❑ I PRODUCT ❑I GASAHOL5 JET fUEt ❑6 AVIATION GAS❑ 5 HAZA ❑ BO EMPTY �UNKNOWN ❑2 WASTE ❑ i METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW)) D. IF NOT MOTHICLE FUEL ENTER NAME OFHAZARDOUSTANCE STORED 6 C.A.S.% %III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.S.C,AD A TYPE OF ❑ I DOUBLE WALLED ❑7 SINGLE WALLED WITH EXTERIOR LINER95 . SYSTEM ❑2 SINGLE WALLED I SECONOARYCONIANMENT OWN ❑99 OTHER B.TANK ❑ 1 STEQ/RON ❑2 STAINLESS STEEL ❑T FIBERGLASS ❑I STEEL QAO w1RBEAGASS REIFORCEO MASTIC MATERIAL ❑5 CONCRETE ❑6 POLYVINYL CHORION ❑ 1 ALUMINUM 08 100%MMMOLCOUPATI&f FW ❑ 9 BRONZE ❑ 10 GALVANIZED SIEEI EI5 UNKNOWN ❑99 OTHER C.INTERIOR ❑ I RIBBER LINED ❑2 ALKYD LINING .... ❑ 9 EPOKYUNING ❑ 1 MIENDL1CLuaNG LINING ❑ 5 GLASS LINING ❑6 UMM(0 I I Q%UNLNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL' ❑YES [:3 NO ❑99 OTHER . D. CORROSION ❑ I POLYETILEN E WRAP ❑ 2 TAR OR ASPHALT ❑ 7 VINYL WRAP ❑ /FIBERGLASS REINFORCED MASTIC PROTECTION ❑ 5 GTHWCM70TECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROVNO.BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U T GRAVITY B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 0 LINED TRENCH A 95 UNPIN O A U 99 TIMER A U I STEELNUM A U 2STArolES$SIFH A ALUMINUM C. MATERIAL A u s ALUMINVM U J POLYVINYL CHLORIDE(PVC) A U I FIBERGLASS PIPE A U 6 CONCRETE 4 U / STEEL CLAD W/FHP A U B 100%METHANOL COMPATIBLE FHP A U 9 GALVANIZED Si' A U"9SUNIZRO�YPn w U 99 OTHER ' V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY.OR S FOR SECONDARY.A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S )VADOSE WELLS P S A P S 6 PRECISION TESTING P S Y PRESSURE TESDNG P ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 91 NON P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE E$IIMATED DATE LAST USED IMOIYNI ) ESNMAi EO OUANiI IY-OF ) WAS TANK F,gLEO WITH 1 SIMSIANCE REMAINING IN INERT MATERIAL' ❑ __..__. ,__. ..._ _ GALLONS YES [:j NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,ANO TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT APPLICANT'S NAME IIMINI F.II g SII INA TWO) O� F!•. LOCAL AGENCY USE ONLY COUNTY 1 JURISDICTION P AGENCY, FACILITY IDI TANK 10 I CURRENT LOCAL AGENCY FACILITY 10• . D O O �i APPROVED BY NAME PHONE F WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION GATE ' CHECK I pERMTT AMOUNT SURCHARGE ANT. FEE CODE RECEIPT• BT: FORMS 134.881 THIS FORM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY )) L 1 We.u:dY^.:�GIi16IP,U..•••J.Y.,t%YTY":Liv.` - V�¢n.:C I