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TANK TANOERMIT APPLICATION INFORMON ; COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATIO90FOR EACH TANK. °•`a MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE P TANK ONE ITEM ❑ 2 INTERIMPERMIT ❑ / AMENDEOPERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED J� FACILITY/SITE NAME WHERE TANK IS INSTALLED: QU FARM TANK-YES❑ NO 7 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 10 Y:' A. OWNERS TANK IDN B. MANUFACTURED BY- Lc—YEAR CYEAR INSTALLED D. TANK CAPACITY IN GALLONS: A H. TANK CONTENTS IF(A.i),IS MARKED,COMPLETE ITEM C.IF(A.T),IS NOT MARKED,COMPLETE ITEM D. N A. ❑ I MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL N ❑ 3 CHEMICAL PRODUCT ❑4 OIL ❑ I PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ BO EMPTY ❑95 UNKNOWN E] 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.N CAS.N: XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C.B D A.TYPE OF ❑ I DOW WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTMNENT ❑99 OTHER B.TANK F11 STEEL/IRON ❑2 STAIKLESS EEL ❑3 FIBERGLASS ❑ /STEEL OMW/FIBERGLASS REN FORM PLASTIC 'T MATERIAL ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑6 100%ME7NANOl COMPATIBLE FAP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER _ C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑ /PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED 1 ❑95 LWNO'WN ❑ IS LINING MATERAL COMPATIBLE WITH 100%METHAIal ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ I POLYETHLENEWRAP ❑2 TAROPASPHALT ❑3 VINYL WRAP ❑A FIBERGLASS REINFORCED PLASTIC - - PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER _ IV. PIPING INFORMATION CIRCLE A IFABOVEGROUNO. U IF UNDERGROUND.BOTH IFAPPUCABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER S. 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 IPVCI A U < FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U S 10016 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 S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S %OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I ESTIMATED DATE LAST USED IM07YRI 2 ESTIMATED OUANTITY OF 3 WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL' ❑ YES 0 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 6 SIGNAI URF) pR E I i J LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID N CURRENT LOCAL AGENCY FACILITY ID A APPROVED BY NAME PHONE A WITH AREA CODE /25 - - PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION CHECK A PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT A BY FORM B 0 7z6e1 THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SfTE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED 1 • DATA PROCESSING COPY •