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:MARK ONLY ❑ 1 NEWPERMIT 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION1 MANENTLY CLOSED TANK E ITEM ❑2INTERIM PERMIT I AMENDEOPERMIT ❑6 TEMPORARY TANK CLOSURE EiTfTANK REMOVED /'1�T FACILITY/SITE NAME WHERE TANK IS INSTALLED: /� �- ( Ing/ 'f FARM TANK-YES❑ NO ❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY ' to A. OWNERS TANK IDX B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D, A N A. ❑ I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ I UNLEADED [-]2 LEADED ❑3 DIESEL N ❑ 3 CHEMICAL PRODUCT ❑ ! Olt ❑ I PRODUCT ❑4 GASAHO. ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 60 EMPTY u 95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER IDESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 C A.S.K C.A.S.M. .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A.B.C,A D A TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER F-195 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑A SECONDARY CONTANAAENT ❑99 OTHER S. TANK ❑ 1 STEELIIRON ❑ 2 STNM.ESSSTEEt ❑ 3 FIBERGLASS ❑A STEEL CLAD WIRBER,7ASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑5 IW%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVAMZEDSTEEI ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑ 7 EPDXY LINING ❑1 PHENOLICUMNG -_ LINING ❑ 5 GLASS LINING ❑6 MINED ' ❑%UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH I00%METHANOL' ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLEM WRAP ❑ 2 TARORASPHAI7 ❑ 7 VINYL WRAP ❑1 FIBERGtASSREIMOIKEDPIASTIC PROTECTION ❑ 5 CATHODICNDTECRON 91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER 8.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U "OTHER A U I STEEL/IRON A U 2 STAINLESS STEEI A U 3 POLYVINYL CHLORIDE IPVCI A U ! FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 ?p METHANOL COMPAIIULE FRP A U 9 GALVANIZED STILL A U 95 UNKNOWN A U "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 I VADOSE WELLS P S A ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S E PRECISION TESTING P S I PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S W OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1 FSIIMATEDOATE LAST 115101"OIYRI - ' ESiI"sTED Dl1ANTITV OE -------_-- - 1 I WAS LANK FILLED WITH ---- - — — _- —SUBSI ANCE REMAINING IN GALLONS INERT MATERIAL° ❑YES ❑ NO� 1 _ THIS FORM HAS BEEN COMPLE7 EO UNDER PENALTY(U PERJURY,AND TO THE REST OF MY KNOWLEDGE.IS TRUE AND CORRECT APPLICANT S NAA1F ((rRIN1,11�Sif:YA 1 LANI I b - LOCAL AGENCY USE ONLY COUNTY K JURISDICTION E AGENCY A FACILITY ID A TANK IO R 3 [�] / / CURRENT LOCAL AGENCv fACIUTY ID• APPROVED 6Y q)(N PHONE WITH AREA CODE PERMIT NUMBER PERMIT A"ROYAL DATE PERMIT ER%RATION GATE CHECK! PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT• FORMBI3-7.86) THIS FORM MUST BE ACCOMPANIED BY A FACILITYTSITE APPLICATION, FORM 'A.UNLESS A CURRENT FORMA' NAS BEEN FILED DATA PROCESSING COPY • • i