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I A14K IANK PERMIT APPLICATION INFORMATION Qtl /L COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK f l yMJ MARK ONLY ❑ I NEW PERMIT ❑]RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ad TAN ONE ITEM E]2 INTERIM PERMIT ❑A AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE �ANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO _7 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY I O A. OWNERS TANK ID N —EE] B. MANUFACTURED BY: C. YEAR INSTALLED / D. TANK CAPAGTY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.l),IS NOT MARKED,COMPLETE ITEM D. A N A I MOTOR VEHICLE FUEL ❑2 PETROLEUMB. C ❑ I UNLEADED ❑2 LEADED B DIESEL F-13 CHEMICAL PRODUCT E] 1 OIL N T PRODUCT ❑N GASAHOL ❑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 A C.A.S.N CAS.N. KI11. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOA A,B,C.8 D A TYPE OF ❑ I D IE WALLED ❑]SINGLE WALLED WITH EUEROR LINER ❑95 UNKNOWN SYSTEM IL.l-d1 W4GLE WALLED ❑1 SECONDMNOONIMNMENT 99 OTHER B. TANK STEELARDN ❑2STAINLESS STEEL ED FIBERGLASS ❑1 STEEL CLAD WIFIBERGLASSREwwRGEO PLASTIC •i MATERIAL ❑5 CONCRETE ❑6 POLYVINYL CIEORIOE ❑ 1 ALUMINUM ❑N LOOK METHANOL COMPATIBLE FP ❑9 BRONZE ❑ 10 GALVANIZED STER ❑%UNKNOWN ❑99 OTHER E] I RUBBER LINED 2 AAUDD LINK - ❑ 7 EPDXY LINING ❑1 PNNOLCUMNG C.`INTER`IOR ❑5 GLA45LNING U�T IND I I ❑95 UNKNOWN ❑ IS LINK MATERIAL COMPATELE WITN IOD%METHANOL, ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ I POLYETHLEN WRAP ❑2 TAR OR ASPIW.I - ❑ 7 VINYL WRAP ❑1 FIBERGLASS REINFORCED PLASTIC PROTECTION C]5 CATHOLIC PROTECTION Fj4fAR/NON ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND,BOTH IF APPLICABLE L A SYSTEM TYPE U I SUCTION _ A U 2 PRESSURE A U ]GRAVITY A U %OTHER 1 B.CONSTRUCTION A U SINGLE WALLED A U 2 DOUBLE WALLED A U D LINED TRENCH A U %UNKNOWN A U 99 OTHER A I STEELIIRON A U 2 STAINLESS STEEL A U l POLYVINYL CHLORIDE(PVC) A U 1 FIBERGLAS6PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U I STEEL CLAD W/FNP A U BILKRF METHANOL COMPAORLE FRP A U 9 GALVANIZED SILEL A U 95 UNKNOWN A U 99 OMEN V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY.A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. i �„II P S I VISUAL CHECK P S I INVEN�TESD� L1AilON P 5 9 VADOSE WELL$ P S I ELECTRONIC MONITOR P 3 5 GROUNDWATER MONITORING WELLS Pvt P S 6 PRECISION TESTING P S I PRESS91 NONE P S 95UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1 ESTIMATED GATE))AST USED IMO/YPLL P ESTIMATED OUANTOY OF I WAS TANK GLUEDWITH $TARSI ANC•REMAINING IN GALLONS INERT MATERIAL' YES ❑ NO� -. _. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE REST OF MY KNOWLEDGE.IS TRUE AND CORRECT APPUGANi"$NPM•KPRINI F D A SIGNA I IINI I OATE!•. LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY E FACILITY ID N 3 TANK ID N CURRENT LOCAL AGENCY FACILITY b N APPROVED BY NAME PHONE N WITH AREA CODE QPERMIT NUMBER Z_SURCHARGE T APPROVAL DATE PERMIT EXPIRATION OAIE — -- _-- ---- CHECK N PERMIT AMOUNT _— AMT. FEE CODE - -RECENT•PORMB197-Mj THIS FORM MUST BE ACCOMPANIED Y A FACBJTY/SIIE NpUCATIOK FORM W,UNUESSACURAENT FORMA' HASBEENFILED DATA PROCESSING COPY .' LAe4^•1,YJ',Cu..NYV,i::r!:iFiIAAZJ:lWM..eP61D:.i" �•,••••,.•n^s:...x.:.M.va:�.w,.:..a.r.u-, ,._::.�........�.............._....�.�....