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TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 9&q MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑1 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ A AMENDW PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED r7-77 FACILITYABITE NAME WHERE TANK 18 INSTALLED:69LIVFARM TANK-YES❑ NO 7 1. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 10 A. OWNERS TANK IDN 1 1L B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS. S� G A 11. TANK CONTENTS IF(AAA IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. N A I_ MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ®\DIESEL N ❑ 3 CHEMICAL PRODUCT ❑A OIL _t PRODl1CT ❑1 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS .L=X. ❑ 5 HAZARDOUS ❑ BO EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 1 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF J HAZARDOUS SUBSTANCE STORED 6 CAS.N S a'-n GC a�2 a,*i� CAS.N. KI I I. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,a D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLEDMTH WERIOR LINER •OWN SYSTEM ❑2 SINGLE WAILED ❑1 SECONDARY CONTAINMENT ❑99 OTHER . L/NON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑1 STEEL CUD W/RBERGLAMAEOFORCED PLASTIC B. TANK ❑ MATERIAL 5 CONCRETE El POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑6 100%METHANOL COMPATIBLE FRP ' ❑ 9 BRONZE ❑ 10 GALVANZEDSIEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ I RLIBBERLINED ❑2 ALKYD LUNG ❑ 3 EPDXY LINING ❑ /MC40LCLINING LINING ❑ 5 GLASS LINING ❑6 UNLINED I Tt�95`UM NGWN / ❑ IS LUNG MATERIAL COMPATIBLE WITH LOOK METHANOL ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ I POLYETNFNE WRAP ❑2 TARORASPHMT ❑J Wm WiMD FlBERGIASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 LONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND.BOTH IF APPLICABLE A SYSTEM TYPE A U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U N OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A UNKNOWN A U N OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U < FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A 66 CONCRETE A U 7 STEEL CUD W/FRP A U S 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEO STEEL A 7U 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. r3I VISUAL CHECK P S INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S <ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 6 PRECISION TESTING P S 7 PRESSURE TESTING P 5 91 NONE P 5 95 UNKNOWN P S N OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I ESTIMATED DATE LAST USED(MO/YR1 2 ESTIMATED OUANTITY OF 3 WAS TANK FILLED WITH I ,tel, `J\`(` GALLONS SUBSTANCE REMAINING IN INERT MATERIAL' ❑YES [1] NO J THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT 4PPLICANTS NAME(PRINTED 6 SIGNATURE I 1 LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N F I TANK TO N In 1 o00 CURRENT LOCAL AOE LIT\'IDN APPROVED BY NAME PHONE N WITH AREA CODE LClEMC'l7- 7PCl NUMBER PERMIT APPROVAL DATE PERW EXPIRATION DATE MIT AMOUNT SURCHAIIOEAYT. FEE CODE RECEIPT• BY: I FORM B(3 7-BB) THIS FORM MUST BE ACCOMPANIED BY A FACKTTYYS TE APPUCATN)N, FORM NA',UNLESS A CURRENT FORM•A• HAS BEEN FILED DATA PROCESSING COPY -d�-Y^._'�Aai4�'G r1�':.__.::J['T.'iSfifl3YTJivi,VS6Yi�i:.GW.44�^ .•'.'tl.-�ini�l[Pm,.:: .._ ..�� _ _�-^.