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TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ON;NAME ❑ 1 NEW PERMIT ❑J REIIEV/Al PERMIT ONE ITE ❑SCHANGE OF INFORMATION ❑ 7PERMANENTLY CLOSED TANK ❑2 INTERIM PERMIT ❑ 1 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE FACILITY/SITWHERE TANK IS INSTALLED: �� ❑B TANK REMOVED () Z8� E. C ka K N FARM TANK-YES❑ NO _ I. TANKDESCRIPTION COMPLETE ALL ITEMS-IFUNKNOWN-SO SPECIFY A. OWNERS TANK IDM 1 O B. MANUFACTURED BY: UKW C. YEAR INSTALLED C-L Kfj D. TANK CAPACITY IN GALLONS: � ooO II. TANK CONTENTS IF(A 1),IS MARKED,COMPLETE IT C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. 1� AI MOTOR VEHICLE FUEL ❑2 PETROLEUMN ❑ B' C. ❑ 3 CHEMICAL PRODUCT 1 OIL I UNLEADED -M.12 LEADED 3 DIESEL 1U1 N ❑❑ I PRODUCT ❑p GASAHOL 5 JET FUEL 6 AVIATION GAS 5 HAZARDOUS ❑ 6p EMPTY ❑95 UNKNOWN 4❑J 2 WASTE E] 7 METHANOL Eli 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED B C.A.S.$ C.A.S.p All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B,C,a D A TYPE OF ❑ 1 DOUBLE WALLEO ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ®95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑1 SECONDARY CONTAINMENT ❑99 OTHER S f-] I STEEL/DON El STMNESSSIEEL ❑3 FIBERGLASS ❑ /STEEL CLAD W/FIBERGLASS REWFOR[ED"TIC MATERIAL ❑5 CONOETE ❑6 POLYVINYL CJEDID7 ALUMINIRA ❑ ❑8100%*THANOLGOMPARBLEFIE ❑9 BRONZE ❑ 10 GALVANIZED STEEL 6�95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 ROBBER LINED 2 ALKYD LINING ❑3 EPDXY LINING ❑1 PHENOLOLNNO LINING ❑5 GLASS LINING ❑6 UNLINED 1 95 ❑ IS LINING MATERAL COMPATIBLE NTH IW%METHANOL, ❑YES ❑ NO ❑99 OTHER 0. CORROSION ❑ 1 POLYETHLENEWPAP ❑2 TARORASPHNT ❑ 3 VINYL WRAP ❑A FDERGUSSREDFORCEOPlASM PROTECTION ❑ 5 CATHOOICPIOTECTION ❑91 NONE 9RX95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND.BOTH IF APPLICABLE pA SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER p 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 A FIBERGLASS PIPE C MATERIAL A U I ALUMINUM A U 6 CONCRETE A U 7 STEEL CLADW/FRP A U B LOB%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A( %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 5 3VADOSE WELLS&:S A ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING ► S 91 NONE ®S 95 UNKNOWN P S "OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I ESTIMATED DATE LAST USED IMO7YR) 2 ESTIMATED QUANTITY OF 3 WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL' E]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 6 SIGNA TURF I 04E! P LOCAL AGENCY USE ONLY COUNTY$ JURISDICTION AGENCY$ FACILITY IDP TANKID$ �_ ] a 2 d D p CURRENT LOCAL AGENCY FACILRY ID Y APPROVED BY NAME PHONE$WITH AREA CODE orr<Z2 c-F� iIs�r LCHECKS IT NUMBER PERMIT APPROVAL GATE PERMIT EKWRATION PATE PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECENT$ Br: f0RM B C1 7-BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM'A',UNLESS A CURRENT FORMA' HAS BEEN FILED / --- ___ DATA PROCESSING COPY � J