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<br /> aNk PINIMit>APPLICAtI N INPORMATION } ,
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<br /> P60M Wifiii E 066 i ftiko INPONMIATION OOVI kA60
<br /> mmut 6NLv 1 NEVY PEr�MI r r.1 9 RENEWAL PERMIT S CHANGE OF INFORMATION T PERMANENTLY CLOS
<br /> " ONE ITEC [ 2 INTERIM PERMIT $AMENDED PERMIT S TEMPORARY TANK CLOSURE e TANK REMOVED Pf 9
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<br /> ISA fl11 Y/Rli"E NAME .,. LIR GAMIC 1st 1NRtALLEb .., I AnM LANK-YLS❑ NO
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<br /> i�tlNkNOVIN -std soEcfFrr t 1
<br /> A.OWNERS TANK ION B. MANUFACTURED BY:
<br /> C.YEAR IN9TALID. TANK CAPACITY IN GALLONS:
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<br /> II..TAN 0 ONTV.Nt9 _ „IF.jk%iR, tb,Co� Lkft ITABN 6.10 tA.1),It Not MARK"O, but
<br /> A. 1 MOTOR ABCLE FUEL 2 PETtLEUM B. C. 1 UNLEADED 2 LEADED 3 DIESEL
<br /> ®3 CHEMICAL Ej 4 011 PRODUCT 4 GASAHOL ❑5 JET FUEL ®6 AVIATION OAS
<br /> A HAZARDOUS 8b Eti4PTY 95 UNKNOWN 2 WASTE ❑7 METHANOL ®99 OTHER(DESCRIBE IN ITEM D,BELOW)
<br /> D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF
<br /> HAZAAooUR SUSStANCE STORED A C.A.S. C.A.S.N:
<br /> III. TANK bbN TI# ION MANk bNk ITAIrA bill IN bill A,Ir,C,A d
<br /> 1. FlALLED S RNOLE WALLED"WERIDR UNEH ❑M UNKNOWN
<br /> A.tft 6F
<br /> SYSTEM ❑2 MWWALLED 4 SECONDANI'CONTAINMENT ❑99 OTHER
<br /> I St W11ION ®2 STAINLESS STEEL ®3 RBEROLASS ®4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC
<br /> B.TANK ®5CONCRETE 0 6 POLYVINYL CHLORIDE F-11 ALUMINUM ®B 10096ETH
<br /> M /WOL COMPATIBLE FRP
<br /> MATERIAL i ®6 . TE 16 bALVANIZED STEEL [:].95 UNKNOWN ®99 OTHER
<br /> C AOR '1 UIl [D 2 ALKYD UMNO 03 EPDXY U NTNG 4 PHENOLIC LINING
<br /> s Cj s l iNED Q 06 LR1kPK"
<br /> umm , r[—❑194 L NIM Mil L AtIRE WM 10046 MIFNI40L9 YES [-]NO ❑99 OTHER
<br /> 1f.C0"Romm u 1 PbL WRAP ❑B 011 OR AW Ill 3 VINYL WRAP ❑4 FIBMLASS REINFORCED PLASTIC
<br /> S UtHolm,WitEC?1ON 0 411 NONE 05 UNKNOWN 99 OTHER
<br /> IV. PIPINd INPOR MATION! GARGLE A IF AdbVE GROUND,. iF UNDEkGIIOUND,bOTN fE AI*LICADLR
<br /> A,$ ,A,,U ,1 SUCTION,,. A ,U 2 PRESSURE A LI3 GRAVITY I A U 91 NONE A U 95 UNKNOWN A U 99 OTHER
<br /> L 6oNJVtIW0M ,,A U 1 SINGLE WALLED,,,,;A,U $DOUBLE WALLED ,A„.U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN . A U 99 OTHER
<br /> A U 1 STEELlifrON` A U'2 8TAINLE6S STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE
<br /> O.MATERIAL A U 5 ALUMINUM A'06 CONCRETE A U T STEEL CLAD W/PRP A U 6 loll METHANOL COMPATIBLE FRP j
<br /> A U 9 6ALVAM269fEEL A U 66 UNKNOWN A II! 99 OTHER
<br /> V.,LEAK blMICTiON 9Y:�'i�I:I 'CIRCLE EoR PRIMARY,OR 0 FOR SECONDARY.A PRIMARY LEAK DETECTION)bVittiM Mll OF CIRCLED.
<br /> ... �. ,
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<br /> P S 1 VISUAL Cf1ECR W S S 1 f AV'REbbNCiLIATibN 0 6 3 VADOSE*1 0 11 4 ELECTRONIC MONITOR P $ 5 GROUND WATER MONITORING WELLS
<br /> M 11 6 PRECISIONTES (NG, „11eN�'19E tf stfNd: „y ,S ,91 Nl: , A. S 95 UNKNOWN, ;. S 69 OTHER
<br /> VI: INPOIlbN. "IQ ftMANENTLV bLb89b IN OLACE
<br /> 1.ESTIMATED OATS LAST USED(4uf0/YF9) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH
<br /> SUBSTANCE REMAINING IN INERT MATERIAL? n YES r NO
<br /> GALLONS
<br /> CHIS FORA4 HAS(SEEN COAAPL�LJFb UNb€o PENALTY,OFLECOJUEtY',AND tO THE SIEST OF MY KNOWLEDGE,IS TRUE AND CORRECT.
<br /> APPUCANTI NAME(PRINTED A SIGNATURE) DATE
<br /> 0” At Ell
<br /> CouNrr! jURi ICTItlFi Aq€t�CY N FACILITY Id N TANK 10 N
<br /> LOCAL A EA U►i 0i 6T PHONE 6 Will AREA CODE
<br /> PER10T witma 1ir:RMit ApWt01tAL DATE P idw gunkATIoN OATS
<br /> Cwt=9 f9ullCHAR®E Ai1t. MCOi IItc l 6 BY:
<br /> FORM B(O-29i TH16 FORM MOTH ACCOWAMb by A FACR.ITIp$f M APPLICATION, FORM`A', eNT FORMA' HAS SEEN FILED
<br /> DATA PROCESSING COPY
<br />
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