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TANKpp � TANK PERMIT APPLICATION INFORMATION �, • </ COMPLETE A SEPARATE FORM WITH THE FOLLOWING!tIFORMATION FOR EACH TANK. '"• MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWALPERMIT CHANGE OF INFORMATION ❑ I PERMANENTLY K ONE ITEM ❑ 2 INTERIM PERMIT ❑A AMEtA®PEAMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED f FACILITY/SITE NAME WHERE TANK IS INSTALLED: D G/F —FARM TANK-YES NO ❑ _7 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY �� 6 10 A. OWNERS TANK IDE B. MANUFACTURED BY: V l I C. YEAR INSTALLED (I K ID. TANK CAPACITY IN GALLONS: IL TANK C NTENTS IF QLI),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,WUPLETE ITEM D. A. I MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. t UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 1 OIL 1 MR ODUCT ❑1 GASAHOL ❑5 JET FLEE ❑6 AVIATION GAS N ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ T METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED A CALS.M CA.S.N: .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C.L D A TYPE OF ❑ WANED ❑3 SINGLE WALLEDMtN EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 WALLED ❑1 SECONONWCONTAINNENT ❑99 OTHER 1 STEEL/MON ❑2 STAINLESS STEEL El3 FIBERGLASS ❑1 STEEL CLAD W/FIBERGLASS REINFORCED MASTIC MATERIAL B. TANK E] 5 CONCRETE E]6 POLYVINYLCHLORIDE F] I ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ I RIBBERLINFD El2 ALKYDLWING ❑ 3 EPDXY LINING El1 PHENOUCLINING / , LINING ❑ 5 GLASS LINING 1:16 UNLINED $ NOWT! ❑ IS LINING MATERML COMPATIBLE WITH IW%METHANOLT ❑YES NO OTHER 0.CORROSION ❑ I POLYEf/LEIE WIMP ❑2 TAR 011 ASPHALT ❑ NII WRAP ❑1 FIBERGLASS REINFORCEp PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMA ION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND.BOTH IF APPLICABLE 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 LINEO TRENCH A UNKNOWN A U %OTHER A U I STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U A FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUMA U CONCRETE A U I STEEL CLAD W/FRP A U B (SOI,METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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. 5 I VISUAL CHECK - P 5 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S A ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS / P 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 1. ESTIMATED DATE LAST USED PMO/YR) 2 ESTIMATED OUANI ITY OF 3 WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL( ❑YES E:] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT APPLICANTS NAME(PRINTED A SIGNATURE) DIt E 1 � � LOCAL AGENCY USE ONLY COUNTY E JURISDICTION E I AGENCY N -� FACILITY ID E TANK ID N 3 9 = L_L__L_JI a CURRENT LOCAL AGENCY FACILITY 101 S/� A APPROVED BY NAME PHONE I WITH AREA CODE l9�4-(✓ld PERMIT NUMBER PERMIT ROVAL DATE PERMITERARAYNONDATE 1/- Z —90 CHECK MRMIT AMOUNT SURCHARGE ANY. FEE CODE RECEIPTe BY: ✓ I FORM B(31-BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' NAS BEEN FILED ___ DATA PROCESSING COPY