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TANK TAN ( PERMIT APPLICATION INFORP' `TION COMPLETE A S1 iATE FORM WITH THE FOLLOWING INFORMA. N FOR EACH TANK. 'a MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURErg�NK REMOVED ' 9[ FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO ❑ '7 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 10 A OWNYEAR INSTNK 10ALLED 0. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. N A, ❑ I MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ I UNLEADED ❑2 LEADED ❑3 DIESEL N ❑3 CHEMICAL PRODUCT ❑A OR ❑ 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 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 6 C A.S.N C.A.S.N. .111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOR A.B,C,A D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑M SECONDARY CONTAINMENT ❑99 OTHER NgLy B F-1I STEELIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑1 STEEL CLAD W/FSERGIASSRENFORCED PLASTIC ^ MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑8 100M METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER C.INTERIOfl ❑ I RUBBER LINED ❑ 2 ALKYD UNING ❑3 EPOAYLINING ❑ M PHENOLCUMNG LINING ❑ 5 GLASS LINK ❑6 UNLINED I / ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH LOOM METHANOL' YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑1 FIBERGLASS RERFORCED PLASTIC . PROTECTION ❑5 CATHODIC PROTECTION ❑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 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U N 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 ISTEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE IPVCI A U A 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 N OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY.OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 5 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P S < ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S I PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE UST USED(MO7YR) 2 ESTIMATED OUANTITY Of 3 WAS TANK FILLED-WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL' [—]YES ❑ NOl THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED'&SIGNATLIPF I DA,EI, I LOCAL AGENCY USE ONLY COUNTY M JURISDICTION N AGENCY N FACILITY ID E TANK IO S m = = I I o I I 111 CURRENT LOCAL AOENCY FACILITY IDS APPROVED BY NAMEE F iH AREA CODE �S3 .2 s F8 PERMIT NUMBER PERMIT APPROVAL DATE "R EKPIRA N DATE -- CHECK S PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT S BY: FORM B(3x88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRERT FORMA' HAS BEEN FILED DATA PROCESSING COPY