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TANK TAN,ERMITAPPLICATION INFORMON ° COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATIIVOR EACH TANK. td.. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION 1 PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIMPERMIT ❑ A AMENDEOPERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: �U 1�7, �l./ FARM TANK-YES=No TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 10 A. OWNERS TANK IDA 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. -Al. A. ❑ I MOTOR VEHICLE FUEL ❑2 PETROLEUM EL C. ❑ I UNLEADED ❑2 LEADED ❑3 DIESEL N ❑ 3 CHEMICAL PRODUCT ❑A OIL ❑ 1 PRODUCT ❑ A GASAHGL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ BO EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED d C.A.S.A C.A.S.A. MI. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A O A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLEDWITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑A SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑1 STEEL CLAD W/RBERGUSS REA60RCEORASTIC F B MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYL CHLORDF ❑ 7 ALUMINUM ❑B 100%METHANOLCDMPATIBLEFRP ❑9 BRONZE ❑ IO GALVANIZED STEEI ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBERUNED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑A PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED 1 ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WTH 100%METHANOL, ❑ YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP K FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTON ❑ 91 NONE ❑95 UNKNOWN ❑99 OTHER 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 B. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U C FIBERGLASS PIPE C. MATERIAL A- U 5 ALUMINUM A U 6 CONCRETE A U I STEEL CLAD W/FRP A U B 100 METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A 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 3 VADOSE WELLS P S A ELECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 5 99 OTHER V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I ESTIMATED DATE LAST USED IMO/YRI 2 ESTIMATED QUANTITY OF 3 WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL+ ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED A SIGNA I[)HE DO,E 1 I LOCAL AGENCY USE ONLY COUNTY A JURISDICTION K AGENCY w FACILITY ID A TANK IO A m CURRENT LOCAL AGENCY FACILITY 10 F APPROVED BY NAME PHONE WITH AREA CODE PERMITNUMBER PERMIT APPROVAL DATE PERMIT EAPIRATIONp CHECK• PERMIT AMOUNT SUBCHARGEAMT. FEE CODE RECEIPT) BYE �� FORM 0(3 7 88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FOR M `A`,UNLESS A CURRENT FORMA' HAS BEEN FILED _. __ _ • DATA PROCESSING COPY • \�).'J