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TANK ! TANK COMPLETE A SEPPERMIT WI ARAA EFORMWIITH APPLICATION FOLLOWINGIN INFORMATION INFORMATION ON FORACH TANK. �- MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ONE ITEM ❑7 PERMANENTLY CLOSED TANK ❑ 2 INTERIM PERMIT ❑ 1 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED O FACILITY/SITE NAME WHERE TANK IS INSTALLED: .53 /r� vi>° FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—So SPECIFY 1 o A. OWNERS TANK IDN ED). MANUFACTURED BY: -� C.YEAR INSTALLED TANK CAPAGTV IN GALLONS II. TANK CONTENTS IF(A.1),18 MARKED,COMPLETE ITEM C.IF IRA),13 NOT MARKED,COMPLETE ITEM D. A A. ❑ 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. 1 UNLEADED Q ❑ ❑2 LEADED ❑ 3 DIESEL N ❑3 CHEMICAL PRODUCT ❑1 OIL ❑ 1 PRODUCT ❑A GASAHOL ❑5 JET NEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ BO 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 C A.S.N GAS.N: .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERNA LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑1 SECONDARY CONTAINMENT ❑99 OTHER B. TANK 1 STEEL/MON ❑2 STAINLESS STEEL E]3 FIBERGLASS E]1 OR CLAD W/FIBERGLASS REINFORCED FUSTIC MATERIAL ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑9 IOD%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZEDSREL ❑ %UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑1 PHENOLIC LINING LINING ❑5 GL SSUNING ❑6 UNLINED 1 ❑%UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL, ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYETELEWWRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑1 FIBER AASS WINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION 91 NONE %UNKNOWN 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND.BOTH IF APPLICABLE i A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER 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 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CUD W/FRP A U R 1004 METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL 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 BE CIRCLED. P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S I ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S "OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I 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 PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT S NAME(PRINTED ft SIGNAI I IRF) DIV EI H LOCAL AGENCY USE ONLY COUNTY N II( J�UR'IIISDICT�IIION N '� �AGENC�YIIT# FACILITY ID N TANK ID N CURRENT LOCAL �ECNCY FACILITY 10 N APPROVED BY NAME PRO E 1 WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE KKT ER ATION DATE CHECK• PERMIT AMOUNT SURCHARGE AMT. FEECODE RECEIPT♦ BY: RM a RABBI THIS FORM MUST BE ACCOMPANIED BY A FACILTTY/SITE APPLICATION, FORM W,UNLESS A CURRENT FORMA' MAS BEEN FILED DATA PROCESSING COPY