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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 �5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED (2 (,� FACILITY/SITE NAME WHERE TANK IS INSTALLED: ( 1 IN T(TX �346FARM TANK-YES❑ NO _7 I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—So SPECIFY to A. OWNERS TANK 10 cA Ko R. MANUFACTURED BY: (,AKN C. YEAR INSTALLED LAK N D TANK CAPACITY IN GALLONS F/K IJ 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. N A. ❑ I MOTOR VEHICLE FUEL ❑2 PETROLEUM B. CAICIJ C ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL GIkN N ❑3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑t GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY [o 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 CA S.N N KN C.A.S.W VIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,&D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑A SECONDARY CONTAINMENT 99 OTHER ❑ 1 STEEURDN ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FBERGUSS RENFORCED PLASTIC B. TANK 5 CONCRETE 6 POLYVINYLCILOAOE 7 ALUMINUM MATERIAL ❑ ❑ ❑ ❑110D%METHANOL COMPATIBLE RP ❑ 9 BRONZE ❑ 10 GALVANIZEDSTEEL 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RIBBER LINED ❑2 ALKYDLNRIG ❑3 EPDXY LINING ❑A PHENOLOUNNG UNING ❑5 GLASS LINING ❑6 UNLINED I 095 UM(NOMI ❑ IS LINK MATERIAL COMPATIBLE MTH 100%METHANC(l YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYETNLENE WRAP ❑2 TAR OR ASPHALT 3 VINYL WRAP ❑1 RBERGUSSREINFORCEDPIASM F-1PIO PROTECTION 5 CATHOOICTECTION 91 NONE RAJ 95 UNKNOWN 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IFAPPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U N OTHER B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U %UNKNOWN A U 99 OTHER UK 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 B IDD%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A c9 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 A ELECTRONIC MONITOR P 3 5 GROUY.D WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 5 5 UNKNOWN P 5 N OTHER V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I ESTIMATED DATE LAST USED IMOYYRI 2 ESTIMATED QUANTITY OF 3 WAS TANK EILLEO WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIALT YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTSNAME(PRINTED&SIGNATORF) DYI EI b - LOCAL AGENCY USE ONLY COUNTY M JURISDICTION N AGENCY N FACILITY IDP TANK ID N �_ a 0 o 10 10c-2- CURRENT LOCAL AGENCY FACILITY ID• APPROVED BY NAME PHONE 0 WITH AREA CODE ESN C-4 2//6/99 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT UNNATKNIDATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECENT N BY: 1 FORM B 137ae1 THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM•A• HAS SEEN FILED _ DATA PROCESSING COPY J h`�