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AN K APPLICATION COMPLETE A S�AA1�JRM WITHTHE FOLLOWING'IN OORMAT1dN Fo..IEACH TANK. MARK ONLY ❑ I NEWPERMIT ❑ 9 RENEWALPERMIT 5 CHANGE OF INFORMATION ONE ITEM ❑2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑6 TEMPORARY TANK Cl0$UREEire TANQJPERK REMOVEDANENTLY CLOSED TANK FACILITY/SITE NAME INHERE TANK 181NSTALLED: 3' , r' SCORCH P FARM TANK-YES NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 10 A. OWNERS TANK IDM 1 B. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D A A I MOTOR VEHICLE FUEL ❑2PETROLEUM U. (V ,�^,��/ G ❑ I UNLEADED 2 LEADED ❑O DIESEL `7 ❑O HAZARCALDOUS PRODIGY ❑A O0. PRODUCT ❑1 GASAHOL 5 JET FUEL N 5 HA2AROpUS ❑6 AVIATION GAS ❑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 6 C.A.S.Y C.A.S.Y. All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,AD A TYPE OF ❑ 1 DOUBLE WALLED ❑D SINGLE WADED WITH EXTERIOR LINER %UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑1 SECONDARYCONTAINMENT ❑%OTHER B. TANK ❑ 1 STEELARON ❑2 STAINLESS STEEL ❑J FIBERGLASS ❑1 STEEL CUD WIFIBERCAASSREMORCFDEIASTIC E]MATERIAL ❑S CONCRETE ❑6 POLYVINYL MORD ❑ 7 ALUMINUM ❑B IW%METHANOL COMPATIBU FRP 9 BRONZE El 10 GALVANIZED STEER 1:1%UNKNOWN ❑99 OTRER C. INTERIOR ❑ I RUBBER LWED ❑2 AKYDLWING ❑]EPoXY LINING ❑/PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNWED 1 i ❑%IAA(H01W1 ❑ IS LINING MATERIAL COMPATIBLE WITH IOD%METHANOI ❑YES ❑NO ❑NOTHER D. CORROSION ❑ I PMYETHUN WRAP ❑2 TAR OR ASPIMLT ❑7 VINYL WRAP F-1K FBERGIASS REINFORCED PIASTC PROTECTION ❑ 5 CATHODIC PROTECTION ❑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 1 SUCTION A U 2 PRESSURE A U 1 GRAVITY _ A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U ]LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U ISTEEL/IRON A U 2S7MNLESSSTFFI A U D POLYVINYL CHLORIDE IPVCI A U AHBERGLA55 PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U ! STEEL CLAD W/FNP A U 9 GALVANIZED STLEL A U 95 UNKNOWN A U B IDDM METHANOL COMPATIBLE FHP 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 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 1 VAOOSE WELLS P S A ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P Y 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I ESTIMATED GATE LAST USED IMO/Yfll - - 2 ESTIMATED GUANIITY OF .1 WAS LANK FILLED WITH GALLONS - SUBSTANCE REMAINING IN INERT MATERIAL' ❑YES ❑ NO _ THIS FORM HAS BEEN COMPLETED UNDER PENALTY Of PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINT FD A SIGNAI UHF I O^E!•. N � 7 LOCAL AGENCY USE ONLY COUNTY Y JURISDICTION Y AGENCY, FACILITY I TANK ID R eAENTLGC� ENCY FACILITY W E APPROVED BY NAME PHONE 1 WITH AREA CODE - - PERMIT APPROVAL PATE PERMIT EXPIRATION DATE CHECK• PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECENT F BY: FowABpa.efiI THIS FORM MUST BE ACCOMPANIED BYAFACILITY/SITE APPLICATION, FORM 'A',UNLESS ACURRENT FORMA' HASBEENFILED _. DATA PROCESSING COPY -