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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 ❑ 21NTERIMPERMIT ❑ 1 AMENDEOPERMIT ❑6 TEMPORARY TANK CLOSURE 0 TANK REMOVED1L FACILITY/SITE NAME WHERE TANK IS INSTALLED: 5 FARM TANK-YES❑ NOIF .-7 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 10 A. OWNERS TANK IDM B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: A IF(A.1),IS NOT MARKED,COMPLETE REM D. II. TANK CONTENTS IF(A.1).IS MARKED,COMPLETE ITEM C N A. ❑ I MOTOR VEHICLE FUEL ❑2 PETROLEUM B- C ❑ I UNLEADED ❑2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ A OIL ❑ 1 PRODUCT ❑A GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS N ❑5 HAZARDOUS ❑BD 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 A C.A.S.I CA&I'. .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A.B,C.L D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑1 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEUIRON 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑1 STEEL OADW/FBEWAASSREYfORCEDRASTIC B. TANK ❑ 5 CONCRETE ❑6 POLYVINYL DILOROE ❑ /ALUMINUM ❑B LBB%METHANOL COMPATIBLE HIP • MATERIAL ❑ 9 BRONZE IB GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C.INTERIOR F-1I RUBBER LINED 2 ALKYD LINING ❑3 EPDXY LINING El PHENOLICUNNG LINING F-15 GLASS LNING ❑6 LIKINED N [-195 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH IBD%METHANOL, ❑YES [::] NO Ej 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VIM'L 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 S.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(PVCI A U K FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD WIFRP A U S 100%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 S I ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P 5 6 PRECISION TESTING P 5 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S %OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1 ESTIMATED DATE LAST USED IMO/YR) 2 ESTIMATEOOUANTITYOF 3 WAS TANK EILLEDWITH SUBSTANCE REMAINING IN INERT MATERIAL, YES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAMF(PRINTED F SIGNATURF, Oq EI 1 / it LOCAL AGENCY USE ONLY COUNTY I JURISDICTION M AGENCY, FACILITY ID M TANK ID I L/ a .. CURRENT LOCAL AGENCY FACILITY ID I APPROVED BY NAME "ONE I WITH AREA CODE �Ca�rio/ __ PERMIT NUMBER PER WT APPgOVAL DATE PERMIT EKPIRATN)N CHECK F PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT 1 BY: FORM B p 7-681 THIS FORM MUST BE ACCOMPANIED BY A FACILITYZSITE APPLICATION, FORM W,UNLESS A CURRENT FORMA HAS BEEN FILED DATA PROCESSING COPY \� 4