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p� TANK TAN TERMIT APPLICATION INFORM. . ION R COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONE TEARY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENT DOSED K ❑Z INTERIM PERWf ❑ K AMENDED PERMIT ❑6 TE RAR TANK CLOSURE ❑B TANK REMOVED / FACILITY/SITE NAME WHERE AN ML RR6TALLED: s Q FARM TANK•YES NO ❑ 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN- A. OWNERS TANK ID N 80 SPECIFY 10 B. MANUFACTURED BY: C. YEAR INSTALLED U Al D. TANK CAPACITY IN GALLONS: IL TANK ONTENTS IF(A.1).IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM DE A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 3 CHEMICAL PRODUCT ❑A Op T��! ❑ I UNLEADED LEADED ❑3 DIESEL N l� l PRODUCT ❑A CMASAHOL ❑5 JET KIEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ M EMPTY ❑95 UNKNOWN E]2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED IS C.A.S.N CA.S.N XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B,C,B D A TYPE OF ❑ 1 DOUSE WALLED ❑3 SINGLE WALLED MTN EXTERIOR LINER UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑A SECONDARY CONTAINMENT ❑99 OTHER S.TANK ❑ I STEELIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑1 STEEL CUD W/FIBERGLASS FIEM'ORCED PLASTIC ' MATERIAL ❑5 OCINDIETE ❑6 POLYVINYL CICORDE ❑ ]AL INUIT ❑6100%METHANOL COMPATIBLE FRP [-] 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑ I PIN K:UM% LINING ❑ 5 GLASSLNNG ❑6 UNLINED tI UNKNOWN ❑ IS LINING MATERIAL COMPATIBUMTH 100%METKANOL7 ❑YES ❑NO ❑99 OTHER 0.CORROSION ❑ I POLYETNUEEWMP ❑2 TARORASPHAO ❑ 3 V LWRAP IDA FIBERGLASSREINFORCEDPLAS71C PROTECTION ❑ 5 CATHODIC PROTECTION Cl 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 W OTHER B.CONSTRUCTION A LA I SINGLE WALLEDA U 2 DOUBLE WALLED A U 3 LINED TRENCH 5 UNKNOWN A U "OTHER A U ISTEELPRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVCI A U A FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRE TF A U I STEEL CUD W/FRP A U S 100M METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 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 A ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S /PRESSURE TESTING P S E P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1 ESTIMATED DATE LAST USED MO/VRI 2 ESTIMATED QUANTITY OF 3 WAS TANK HE WITH y SUBSTANCE RJ:IfA/NyIG IN INERT MATER LED E$ ❑ N0� GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED 3 SIGNATURF DDI E!, j LOCAL AGENCY USE ONLY COUNTY11 JURISDICTION N AGENCY N FACILITY ID N TANK ID N CURRENT LOCAL AGENCY FACILITY 10 N APPROVED BY NAME PHONE N WITH AREA CODE GG �S _ � �-j YPL PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK• PEpMIT AMOUNT SURCHARGE AMT. PEE CODE RECEIPT F- ry; FORM a 0 7-BBI THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FOR M A,UNLESS A CURflENT FORMA' NAS BEEN FILED DATA PROCESSING COPY