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TANK TAN 3ERMIT APPLICATION INFORM. .. ION s COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION „ ONE ITEM ❑ 7 PERMANENTLY CLOSED TANK ❑2INTEM PERMIT ❑ A AMUEIED PERMIT ❑6 TEMPORARY TAM CLOSURE F. TANK REMOVED O FACILITY/SITE NAME WHERE TANK IS INSTALLED; ,�O N a FARM TANK-YES NO ❑ _7 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN So SPECIFY i0 A. OWNERS TANK ION ' B. MANUFACTURED By.- MET: y.- C.( C. YEAR INSTALLED K D TANK CAPAGTY IN GALLONS ca �i (� 11. TANK C NTENTS IF(A.Ih 18 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM O, v A N A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM 8. C ❑ i UNLEADED 2 LEADED ❑3 DIESEL aa) ❑3 CHEMICAL PRODUCT ❑ 1 OIL IpppppCT ❑A GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS N ❑ 5 HAZARDOUS ❑ 80 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 CAS.N CA.S.N. All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A.B,C,i D A TYPE OF ❑ 1 DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINED 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑1 SECONDARY CONTAINMENT [j 99 OTHER E] 1 STEEUIRI El STAINLESS STEEL ❑3 FIBERGLASS ❑1 STERCLAOW/RBERGUMET NFOREDRASTIC 8 MATERIALF-1❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑T ALUMINUM ❑810014 METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR F-1I RUBBER LINED 1:12 ALKYD LINING ❑ 3 EPDXY UMNG ❑1 PIEHOL C UMNG LINING ❑ 5 GLASS LINING ❑6 UNLINED 1 pMNpyM ❑ IS LINING MATERIAL COMPATIBLE WITH ION METHANOL' ❑ YES ❑ NO 99 OTHER D.CORROSION ❑ I POLYEHLJNE WRAP ❑2 TAR OR ASPHALT ❑3 W WRAP ❑1 FBFK"Z REWORDED RAM PROTECTION 5 CATHODCRIOTECTION ❑91 NONE UNKNOWN ❑0 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 N OTHER S.CONSTRUCTION A U I SINGLE WALLED A U 2 DOABLE WALLED A U 3 LINED TRENCHA U 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 S ALUMINUM AU\6 CONCRETE A U 7 STEEL CUD W/FRP A U 8 t00%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A\/U MI5 UNKNOWN A U "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 RECCNCILIATION P S VADOSE WELLS P S < ELECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S P S %UNKNOWN P S %OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1 ESTIMAT DATE LAST USED IMO7YR1 2 ESTIMATED Ol1ANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAFj(.IN_II�G If� GALLONS INERT MATERIAL? YES [:] IN � THIS FOPk4 HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED 6 SIGNAI r. W DIY EI I � P LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY M FACILITY ID N TANK ID N O 16 a10 10 roll I CURRENT LOOS AG NCY FACILITY ID• APPROVED BY NAME �Sn P1N)NE 1 WITH AREA CODE � GG � 8- IPI , PERMIT NUMBER PERMIT APPROVAL DA RMrt EKMNATMN DATE CHECK I PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY.. FORM B(3 7-eM) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/ ITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY