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I HIVIL I ANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEP�1TE FORM WITH THE FOLLOWING INFORMAT FOR EACH TANK. <br /> • MARK;ITEM <br /> ❑ I NEWPEAMIT %•� <br /> ONE ❑ RENEWALPERMIT $CHTpN2 INTEflIM PERMIT /AMENDED PERMIT ` ❑ T PERMANENTLY CLOSED GNK <br /> 6 TEMPORA(N TANK CLOSURE B TANK REMOVEDFACILITNAME WHERE TANK IS INSTALLE7 ) <br /> FARM TANK-YES NO _ <br /> L TANKDESCRIPTION COMPLETE ALL ITEMS•IFUNKNOWN—SO SPECIFY <br /> A OWNERS TANK ID F 1 p <br /> B. MANUFACTURED BY: C) . <br /> C.YEAR INSTALLED v. K. <br /> D. TANK CAPACITY IN GALLONS: 1122 Lz'v <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. LT <br /> A E3 I MOTOR VEHICLE NEL C3 2 PETROLEUM B. C. ❑ UNLEADED PLEADED D DIESEL <br /> E3 D CHEMICALPRODUCT /OIL I U <br /> ED 5 HAZARDOUS BO EMPTY 95 UNKNOWN I PRODUCT 1 GASAHOL 5 JET FUEL - 6 AVIATION GAS N ' <br /> 2 WASTE D T METHANOL 99 OTHER(DESCRIBE M ITEM 0.BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED 6 C.A.S.F K <br /> ,1111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,13.C. <br /> GAS.F. <br /> A TYPE OF ❑ 1 DOUBLE WALLED [_j 7 SINGLE WALLED N TN EXTERIOR LINER �%UNKNOWN <br /> SYSTEM 1 SINGLE WALLED 1 SECONDUWCONINNMENT <br /> 99 OTHER <br /> B.TANK ❑ ISTEELARON iSTAINLESS STEEL TFIBERGLASS N STEEL CUD WIRBERGW$REINFORCED PLASTIC <br /> MATERIAL ❑ 5 CONCRETE ED6 POLYVINYL OLOROf I ALUMINUM [:D 6 10D%METHANOL COMPATIBLE FRP <br /> El 9 BRONZE El 10 GALVAH ZEO STEN a%"Now" ❑%OTHER <br /> C.INTERIOR ❑ 1 RIBBERUNED EIZALKYO LINING 2222.. IJ 7EPDXY LINING /PHENOLICUNING <br /> UNING ❑5 GIASS LINING F�6 UNLINED 1 1 I- 195 UNKNOWN <br /> El R LINING MATERIAL COMPATIBLEri1TN 100%METIavK)L'1 ❑YES E]NO ❑99 OTHER <br /> D.CORROSION I POLYETKINE wRAP O 2 TM OR ASPHALT .__❑ 9 INiL WRAP /fIBERGLl55 REINFORCED PLASTIC <br /> 5 CATHODICPRp7ECtK7N 11 91 NONE %UNKNOWN [3 99 OMER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A SYSTEM TYPE A LA I __[ N A U 2 PRESSURE A U ]GRAVITY - <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U } pOUeIE WALLED A U ]LINED TRENCH U_"OTHER <br /> A LA I STEELnRON A yU N A U 99 OTHER <br /> C. MATERIAL u ? STugLESS STEFI A <br /> A U S AWMU 7 POLYVINYL CHLORIDE IPVCI A U I FIBERGLASSP[PE <br /> INVM A U 6 CONCRETE A U 1 STEEL CLAD W/FRP <br /> A U 9 GALVANIZEDSILEL—A�•�-���•. A U 61ppU METHANOL COMPATIBLE FRP ' <br /> 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 5 1 VISUAL CHECK P $ 2 INVENTORY RECONCILIATION P S 7 VADOSE WELL$ PS N ELECTRONIC MONITOR p $ 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S I PRESSURE TESTING p $ 91 <br /> P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATEOOATE LAST USED IMOYYRI --- <br /> - 7 ESTIMATED pUANT11Y Oi l WASTANI(FILL ED WITH <br /> SOUSIANCE REMAINING IN INERT MATENA11 <br /> GALLONS �YES E]NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT <br /> 4PPLICANi'$NAME IItl11NIFD A 511:nA ll1RF 1 ' <br /> DKS f I•. <br /> 1 1 <br /> LOCAL AGENCY USE ONLY n <br /> COUNTY 1 JURISDICTION F AGENCY I <br /> �_ __�_ --n O D FACILITY <br /> i"I K _1 � '•� ONK TDF <br /> n <br /> CURRENT IOCAI AGENCY FACILITY 10 <br /> APPHOVED BY NAME PHONE I WITH AREA CODE <br /> PERMIT NMMBER PERMIT APPROVAL DATE <br /> PERMIT EXPIRATION GATE ' <br /> CNECKI PERMIT AMOUNT SURCHARGE AMT. FEE CODE <br /> RECEIPTI BY: <br /> FORM epa-BB) THIS FORM MUST BE ACCOMPANIED BTAFACILTTYFSITEAPPLICATION, FORM 'A�,UNLESS A CURRENT FORMA• HASSEENFILED <br /> DATA PROCESSING COPY <br /> \•ti - .. - - 2222 J <br /> a.•:;ti'.:„I,c'1:ia:r_.::�slTaP.rm.cr..ra>nru.ro-�..:: x �::.:� ". <br />