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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 ANGE OF INFORMATION ❑ 2 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIMPERMIT ❑A AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED /Z7 FACILITY/SITE NAME WHERE TANK IS INSTALLED: F RM TANK-YES NOPr _7 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY O A. OWNERS TANK ID N _ B. MANUFACTURED BY: I C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: A 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. i V A_ ❑ I MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ I UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑4 GASAHM ❑5 JET FUEL ❑ 6 AVIATON 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 C.A.S.N C A S.N. All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A.B,C,S0 A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED NTH EXTERIOR LINER ❑95 LWNOWN SYSTEM ❑2 SINGLE WAILED ❑A SECONDARY CONTAINMENT ❑99 OTHER F-1I STEEL/NON ❑2 STAINLESS STEEL ❑3 fIBER AAti5 ❑1 STEEL CLAD W/FIBERGLASS REN60RCED PLASTIC B. TANK ` MATERIAL ❑ S CONCRETE ❑6 POLYVINYL CHLORIDE F-12 ALUMINUM ❑B I00%MERMIIOLCOMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR I RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑I PHENOLIC LINING LINING ❑ 5 GLASS LINING F-16 U LINED I ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATNAE WITH IW%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WAP ❑I FBEWAASS 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 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 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 U0 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 INVENICRY RECONCILIATION P S 3 VADOSE WELLS P S < ELECTRONIC MONITOR P 5 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 5 "OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I ESTIMATED DATE LAST USED IMO/YRI 2 ESTIMATED OUANTITY OF 3 WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ NEI] THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT APPLICANTS NAME(PRINTED A SIGNATURF 1 pYY FI. LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY A FACILITY ID N TANK IO N m =-. = I I 111 -IeAolq-1 CURRENT LOCAL AGENCY FACILITY 10 N APPROVED MY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMITEXMRATION PATE tl CHECK. PERMIT AMOUNT SURCHARGE AWT. FEE CODE RECEIPT By, FORM B 13 7 BB1 THIS FORM MUST BE ACCOMPANIED BY A FACILRY/SQE APPLICATION, FORM 'A'.UNLESS A CURRENT FORM•A• HAS BEEN FILED DATA PROCESSING COPY