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TANK /ZTANK PERMIT APPLICATION INFORMATION [� T/ COMPLETE A SEPARATE FORM WfTH THE FOLLOWIN INFORMATION FOR EACH TANK 'A• o MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C D ANN ONE ITEM ❑ 2 INTERIM PERMIT ❑A AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE [:]a TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: , (^ iyA,,., " -7fAR=NK-YESLLj NO ❑ —7 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 10 A. OWNERS TANK ID N _ B. MANUFACTURED BY: t C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: A 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.i),IS NOT MARKED,COMPLETE ITEM O. (V A ❑ I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM W C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL N ❑ 3 CHEMICAL PRODUCT ❑ A OIL ❑ 1 PRODUCT ❑A GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑60 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 6 C.A.S.N CAS.N. .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B.C.B D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED NTH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑ 2 SINGLE WAILED ❑N SECONOARYCONROWN7 ❑99 OTHER ❑ I STEEu DN E]2 STAINIESSSTEEL ❑ 3 FIBER AAS3 ❑1 STEEL CUD WIF18EAWM REWORDED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYWNYLCHORM ❑ 7 ALUMINUM ❑6100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GAIVANIZEDSTEEI ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPOKYLINING ❑1 PHENOUCUMNG LINING ❑ 5 GLASS LINING ❑6 UNUNED N ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATMIE WITH 100%METHANOL' ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYETL%ENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑1 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑95 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 1 S.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 STEELMRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U e FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U > STEEL CLAD W/FRP A U 6 100%METHANOL COMPAIIBLE FRP 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 BE CIRCLED. P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S C 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 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I ESTIMATED DATE LAST USED IMO/VRI 2 ESTIMQEO pUANTIlY Of 3 WAS TANK FILLED WITH �1 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 aINI ICANT S NAME(PAINTED N SIGNATURF) I LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK IO N �_ �� - U lo CURRENT LOCAL AGENCY FACILITY ID APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBERPERWT APPROVAL DATE PERMIT EXPIRATION DATE CHECK F PERYIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT F elf. ' FORMB(37m) THIS FORM MUST BE ACCOMPANIED BY A FACILITYISM APPLICATION, FORM'A,UNLESS A CURRENT FORMW HASBEENFILED DATA PROCESSING COPY