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TANK TANK PERMIT APPLICATION INFORMATION , COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK, '".. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERNA PERMIT ❑ A AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO ❑ 7 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY Ip A. OWNERS TANK ID% B. MANUFACTURED BY: C. YEAR INSTALLED D TANK CAPAGTY IN GALLONS' 11. TANK CONTENTS IF(A/),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A N A. ❑ I MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C ❑ 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑A OIL ❑:1 =7 T ❑A GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS❑ 5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑ ❑ 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.K C.A.S.IT All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B,C,6 D A TYPE OF ❑ I DOABLE WALLED ❑3 SINGLE WALLEM MTN EXTERIOR LINER ❑95 UNKNOY/II SYSTEM ❑2 WEE WALLED ❑ I SECONDARY CONTMAENT ❑99 OTHER B. [:jI STEEUDON ❑1 STAINLESSSTEEL ❑3 FIBERGLASS ❑1 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC '1 TAN [-]5 CONCRETE ❑6 POLYVINYL CHLORO ❑ 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING F-13 EPDXY LINING ❑/PHENOLIC LINING / LINING ❑ 5 GLASS LINING E]6 UNWED I El B UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE MTN 100%METHANOL' ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENEWRAP ❑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 A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U W OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U A FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U T STEEL CLAD W/FRP A U 8 IDOW METHANOL COMPATIBLE 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 5 1 ELECTRONIC MONITOR P 5 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(MO/YR) 2 ESTIMATED QUANTITY OF 3 WAS TANK FILLED WITH 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 APPLICANT'S NAME(PRINTED S SIGNATURFI 1 A LOCAL AGENCY USE ONLY COUNTY 0 JURISDICTION A AGENCY A FACILITY ID N TANK ID R aw = I I I O .. CURRENT LOCAL AGENCY FACILITY 10 A APPROVED BY NAME ��/y� PHONE A WITH AREA CODE �� __ U PERMIT NUMBER PEgMIT APPROVAL GATE PERM) E%PIR ION DATE CHECK A PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT 1 SY. i I FORM B Cl/-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FOR M 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY j