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IAIN LICATION AN K COMPLETE A SEP K PERMIT TE FORM WITHPTHE FOLLOWIN IN OORMAMDYApOR,EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑G RENEWAL PERMIT 5 CHANGE OF INFORMATION ONE ITEM ❑ 1 PENCLOSED TANK ❑2 INTEflIM PERMIT ❑ A AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANKK REMOVED D FACILITY/SITE NAME WHERE TANK IS INSTALLED; FARM TANK.YES NO 0 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN— so sveaFr 1O A. OWNERS TANK ID M B. MANU C. YEAR INSTALLED FACTURED BY: 0. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.11,IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. ? A. ❑ 1 MOTOR VEHICLE FUEL 2 PETROLEUM R. N ❑ � C ❑ 1 UNLEADED ❑2 LEADED ❑O DIESEL ❑ O CHEMICAL PRODUCT ❑ A OIL ❑ 1 PRODUCT ❑1 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS N 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.M CA S,A All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B,C.S D A TYPE OF ❑ I DOUBLE WALLED ❑0 SINGLE WALLED WITH EXTERIOR LINER ❑95 LWKNOWN SYSTEM ❑2 SINGLE WALLED ❑1 SECONOAIT/CONTALNMENT ❑99 OTHER B.TANK ❑ I STEELIRON ❑2 STAINLESS STEEL ❑ 7 FIBERGLASS El STEEL CUD WTFIBERGIASS REINFORCED PLASTIC MATERIAL ❑S CONCRETE El POLYVINYL CIEORDF ❑ 7 ALUMINUM ❑S IBIx METHANOLCOMPATIBLE HP ❑9 BRONZE ❑ 10 GALVANILEDSTEEI ❑95 UNKNOWN El"OTHER C. INTERIOR ❑ 1 RUBBER LNIFD ❑2 ALKYO LINING ❑7 EPDXY LINING ❑1 PHENDICUNING LINING ❑5 GLASS LINK ❑6 UNLINED f i ❑95 UNKNOWN Cl IS LNING MATERIAL COMPATIBLE WIN TOOK METHANOL+ ❑YES ❑ NO ❑NOTIER D. CORROSION ❑ 1 KXYETHLENEWRAP ❑ 2 TAR OR ASPHALT ❑O VINYL WRAP ❑1 FBERGUSS REINFORCED REAM PROTECTION ❑ 5 CATHONCPNDTECTON ❑91 NONE ❑95 UNKNOWN []99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND.BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 7 GRAVITY _ A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 9 LINED TRENCH A U 95 UNKNOWN --- A U 99 OTHER A U I STEEL/IRON A U 2 SIAINLESSSTEEI A U 9POLYVINYLCHLORIDE(PVC) A U A FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U I STEEL CLAD W/FNP A U B IOOKMETHANOL COMPATIBLE TRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST SE CIRCLED. i P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S T VADOSE WELLS P S I ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 5 7 PRESSURE TESTING P S 91 NONE P 5 95 UNKNOWN P 5 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1 ESTIMATED GATE LAST USED IMO/YNR ESTIMATEDOUANIIIYOf I WAS TANK EILLEO WIIN -- � ' SUBSTANCE REMAINING IN INERT MATERIAL'_ GALLONS E]YES ❑ NU] THIS FORM HAS DEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME IMi1N1 f D 6 SIGNA I LFII I OA,E!•. 1 J J LOCAL AGENCY USE ONLY COUNTY F JURISDICTION F AGENCY A F .ILITY 10• TANK ID E C NT LOCAL AGENCY FACILITY 10 APPROVED BY NAME PHONE 1 WITH AREA CODE PERMIT APPROVAL DATE PERMIT"MRATION DATE CHECK• PERMIT AMOUNT SURCHARGE AML FEE CODE RECEIPTS BY: \FOTEuew-r-BBI THIS FORM MUST BEACCOMPANIED BYA FACILITY/SITEAPPLICATION, FORM 'A',UNLESSACURRENT FORMA HASBEENFLED I 0\1 DATA PROCESSING COPY j t'at}p.4�xT15,'<CN..IG.�i:A,"`..•Yr.3iFrlRSJ�tE71SPP.L. ..,.