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TANK TANK PERMIT APPLICATION INFORMATION ; COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACHMARK ONLTANK ONE ITEMT ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ❑2 INTERIM PERMIT ❑ 1 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑e TANK REMOVED ©� FACILITY/SITE NAME WHERE TANK IS INSTALLED. FARM TANK-YES� NO Io _7 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK IDN B. MANUFACTURED BY: - C. YEAR INSTALLED "/4f D TANK CAPAGTY IN GALLONS '3 0 II. TANK CONTENTS IF(A1),18 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETEJTEM D. ? N A. PiLI MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED Pa_2 LEADED ❑3 DIESEL N F-13 CHEMICAL PRODUCT ❑ / OIL ® I PRODUCT ❑/GASA OL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 60 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ T METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW( D. IF NO7 MO70R VEHICLE FUEL,ENTER NAME OF HA ZAROOUS SUBSTANCE STORED 6 C A.S.N C.A.S.p. .111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,8,C,i D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WAUM NTH EXTERIOR LINER 95 UNKNOWN —SYSTEM ❑2 SIWAE WALLED ❑1 SECONONII'CONTAINMENT ❑99 OTHER 1 STEEL/IDN ❑2 STAINLESS STEEL ❑TANK3 FIBERGLASS ❑/SIEELCLAOWIRBERfiIASS AEOIFORCFD PLASTIC') B MATERIAL ❑5 COMPETE ❑6 POLYVBWL CHLORIDE ❑ 7 ALUMINUM ❑e IOD%METHANOL COMPATIBLE RIP ❑9 BRONZE ❑ 10 GALVANIZEDSTEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RIBBER LINED ❑2 ALKYD ENING ❑3 EPDXY LINING ❑1 PHEN LC LMNO LNIING ❑ 5 GLASS LINING ❑6 UNLINED 1 rrJ,L LWMCWN 1 ❑ IS LINING MATERIAL COMPATIBLE MTH 100%METHANOL, ❑YES ❑ Np ❑99 OTHER D. CORROSION ❑ I PDLYETH ENE WRAP 2 TAR OR ASPHALT ❑ VINYL WRAP ❑/FBBIGAW REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTIBR IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND.BOTH IF APPLICABLE A SYSTEM TYPE A 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 CU>5 UNKNOWN A U 99 OTHER A U ( STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U < FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 95 UNKNOWN 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 1B METHANOL COMPATIBLEFRP A U 9 GALVANIZED STEEL 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 ELECTRONICMONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTIN P 5 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3 WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL( ❑YES [:] NO THIS FORM HAS BEEN COMPLETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAMF(PRINTED A SIGNA TURF! DIS E 1 LOCAL AGENCY USE ONLY COUNTY p JURISDICTION N AGENCY N FACILITY ID NTANK ID p CURRENT LOCAL AGENCY FACILITY R)• APPROVED BY NAME PHONE N WITH AREA COOE {fp2 c PER IT NUMBER PERMIT APPROVAL DATE PERMITEXPI ATIONDATE CHECK F PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT. BY: 777 FDRMBI37-BS) TMIS FORM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FO R M 'A',UNLESS A CURRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY \ � r