COMPLIANCE INFO_1985-1992 - Laserfiche WebLink

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TATE OP` ALIFOAN1 7 uvAt I E> bill CEs CONN OAab o. .,. ip, y� J� �.. 1 'g r �� NDE . A7117V/ Y TO E t N O A '� s o 'LANK SEI% IIT APPLIWION INIa�AMOION :. % PL A I A i'0 PoRM VI"ir t lidt.L lka iNPOINMATiON fitDih IAO tANE.`' '' MANK C1NL NEW PERMIT " RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY C S ONE I tIMI" ❑2 INTERIM PERMIT ®4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FAplu"/Ir it NAME*HERE TANK I6 INStALLED: �7 !�,GI/t? 1 _ 44-FARM TANK-Yt$ NO � I. TANK SDE CRIPtIg".µ..�blvfAMNk A. OWNERS TANK Ib 4" . B. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: If. TANK NTENT$ MMAI%kED,COMPLETE ITEM D. A. 0j MOTOR VEHICLE FUEL ❑2 PETROLEUMB. C. F-11 UNLEADED 2 LEADED F-13 DIESEL ®3 CHEMICAL PRODUCT, ®4 OIL 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑8 AVIATION GAS ❑5 HAZARDOUS ®8b EMPTY 95 UNKNOWN ❑2 WASTE ❑7 METHANOL ®99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTAN E STOAtO A C.A.S.# C.A.S.9: Ill. TANK CONT. CTION MANK ONE litM ONLY IN BOX A,0,0.At D A.TYI#OF if DOUBLE WALLED ❑3 W4LE WALLED ATN MERIDA UNER ❑95 UNKNOWN SYSTEM ®2 SINGLE WALLED 4 SECONDARY CONTAINMENT ❑99 OTHER F-1fEEi. I SIIRON ❑2 STAINLESS STEEL F-13 FIBERGLASS F-14 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑g CONCRETE ®8 POLYVINYL CHLOFmt F-17 ALUMINUM F-18 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONtE W GALVANIZED STEEL ❑96 UNKNOWN ®99 OTHER C.INTERIOR ❑l i RUBBER LINED ❑2 ALKYD UNING ®3 EPDXY UNING ❑4 PHE14OUC UNING LINING t_I 5 GLASS LININ(; n 8 UNLINED ❑95 UNKNOWN I§UMNG MATMAL COMPATIBLE WITH(i A METHA(OLl [:]YES ®NO ❑99 OTHER D.CORROSION Ej I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ®4 FIBERGLASS REINFORCED PLASTIC IRbTi CTION5 CATHODIC PROTECTION [--](9I Nm 66 UNKNOWN 99 OTHER ❑ _J ®, ❑ IV. PIPING INPOR MATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,sotA IE AIPIPLICAELE A.SYSTEM TYPE A U i SUCTION .; A, U 2.PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U i SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER I A U I STEEL/IRON" A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE It MATERIAL A U 9 ALUMINUM A N S CONCRETE A U 7 STEEL CLAD W/FRP A U S 10096 METHANOL COMPATIBLE FRP A U $GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. 4AK DETECTION 5YE'tEM C(RCLE'14 FOR PRIMARY,OR 0 FOR SECONDARY,A PRIMARY LEAK DETECTION SYR§TEM MUST BE CIRCLED. P 8 1 VISUAL CHECK P # 9 INVENTORY mtb6 C UATiON 0 6 3 VADOSE WELLS P # 4 ELECTRONIC MONITOR P B 5 GROUND WATER MONITORING WELLS P 9 6 PRECISION?EStiN(i P # 17,PFIESSUIiETESTING. ii 6..•91 NONE P S 95 UNKNOWN_ P S 99 OTHER VI. INPOAMATION ON LANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLON>'i INERT MATERIAL? ❑YES ❑NO TMIS PORM HAS BEEN COAAPLLtEb UNbEP PENALTY OF PERJURY,AND TO THE GEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL.AGEN Y SSE ONLMiami COUN tY II„ �tlRIECiC t10Pi#n r _ACitNGY# FACILITY ID TANK ID# CURRENT LOCAL AGENCY PACR,ITY ID# APPROVED NY NAME PHONE A WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CODE] CHECK# PERMIT AMOUNT RURCHARGE AMT. FEE CODE RECEIPT# BY: W FORM B(s-29-se) THIS FORM MUST RE ACCOMPANR?d IV A FACILITY/SITE ATIOK FORM'A',UNLESMRRENT FORMA' HAS BEEN FILED nATA oonr oatumn r►nov