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I HIVK IAIVK eLHMIY APPLICATION INFORN `TION COMPLETE A SE ATE FORM WITH THE FOLLOWING INFORMRv1 FOR EACH TANK. �� • MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION ONE ITEM ❑ 2 INTERIM PERMIT N AMENDED PERMIT ❑ 1 PERMANENTLY CLOSED TANK 6 TEMPORARY TANK CLOSURE 0 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLE !nf 09 FARM TANK-YES NO I. TANK DESCRIPTION COMPLETE AIL ITEMS-IF UNKNOWN So SPECIFY A. OWNERS TANK ID N L 10 8. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(AI),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM A A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUMB. C. UNLEADED 2 LEADED f V ❑ t❑ 3 CHEMICAL PRODUCT ❑/OK Im ❑ 3 DIESEL 5 HAZARDOUS t PRODUCT ❑N GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS TV ❑00 EMPTY Q]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.N C.A.S.N. .III. TANK CONSTRUCTION MARKONEITEMONLYINBOXA S,C,LD A TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER %UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑K SECONDMYfgNINNMENT ❑99 OTHER B. TANK I STEELIROH ❑2 STAINLESSSTEEL 3 FIBERGLASS ❑1 STEEL GAD W/FIBERGLASS RENEORCEo"TIC MATERIAL ❑5 CONCRETE ETE ❑6 POLYVINYL GILOINDF ❑ 1 ALUMINUM ❑1100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ I0 GALVANIZED STED ❑ %UNKNOWN ❑%OTHER C. INTERIOR ❑ I RUlWRLYED ❑2 ALKYO LINING ❑ 3 EPDXY LNNW, ❑1 PNENOLCLIMNG LINING ❑5 GLASS LNING 6 UNLINED I I %UNKNONN IS LINING MATERIAL COMPATIBLE WITH IIXI%UETtMNOLT YES 0 N 99 OTEER D. CORROSION ❑ 1 POLYETMEWWRAP ❑2 TARO ASPHAL7 ❑3 VINYL WRAP ❑K FIBERGLASS FEIWORCEO PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑ 91 NONE ❑%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 3 GRAVITY A U 99 OTHER 8. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL A U I STEEL/IRON A U 7 STAINLESS STILL A U 3 POLYVINYL CHLORIDE(PVC) A U A FIBERGLASSPIPE A U 5 ALUMINUM A U 6 CONCRE It A U I STEEL CLAD W/FRP A U B lfO%METHANOL COMI'AOOLE FNP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY.OP S FOR SECONDARY.A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. i P S I VISUAL CHECK P S 2 INVENTORY RECONCILIAtION P S 3 VADOSE WELLS P S < ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I ESTIMATED GATE LAST USED LMO/VRI ESTIMATFDOUAN71 OFOF t WAS TANK FILLED M7H ' SOBSIAN(.E REMAINING IN GALLONS INERT MATERIAL' ❑YES 0 NO] 11 THIS FORM HAS BEEN COMPLETED UNDER PENAL TY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT APPLIGANi'S NAME IPRINIFD A SIfSNA 1URF I I LOCAL AGENCY USE ONLY oqE!•. COUNTY N JURISDICTION N AGENCY N FA N �{( TANK ID N ` J' CZ�AGENCVFAC:'L�� APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMRER PERMIT APPROVAL DATE ►ERMIT EXPIRATION DATE -- CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT er: FORMB137-ea) THIS FORM MUST BE ACCOMPANIED BY A FACILTIY/SITE APPLICATION, FORM 'A',UNLESSACUflRENT FORN'A' MAS BEEN FILED DATA PROCESSING COPY f'K}Li63B17:dR!U7:iIW^i:Y'J5iRiNRf�WNX6�Cl<T•:".,� .�--•nec:,..u.:.uu,u.....,.__.uAm.,:_-,_.................�_.._......_.________ . _