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I ANK I ANK PERMIT APPLICATION INFORM --ION �IrI COMPLETE A SEP .TE FORM WITH THE FOLLOWING INFORMAT �� . !." L�FOR EACH TANK. �",. MARK ONLY ❑ I;NEWPERMIT ❑G RENEWALPERMIT ❑ 5 CHANGE OF INFORMATIONONE ITEM ❑2 PERMIT ❑ / PERMANENTLY CLOSED TANK ❑1 AMENDEDPERMIT ❑6 iEMPOgAq'Y TANK CLOSURE TANK REMOVEDFACILITY/SITE NAME WNEaIS INSTALLED: G` �j� 1. TANK DESCRIPTION COMPLETE ALL ITEMS•IF UNKNOWN—SO SPECIFY FARM TANK-YESfo NO ❑A. OWNERS TANK ID N �� B. MANUFACTURED BY: C. YEAR INSTALLED O. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM . A TIOR VEHICLE FUEL ❑2 PETROLEUM 8. C. ❑ I UNLEADED 2 LEADED ❑7 DIESEL MICALPRODUCT 1 011❑ �+ CT ❑1 GASAHOL ❑5 JET FUEL ❑6 AVIATION GASTOR VE ❑ 2 WASTE ❑ / METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) . TOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 CAS.N C.A.S.M. KIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,S D A TYPE OF ❑ I DOUSLE WAILED ❑7 SINGLE WALLED MM EKTERKA LINER ❑%UNKNOWN SYSTEM ❑2$MICAS WALLED ❑1 SECONDARYCONTAINMENT ❑99 OTHER 0.TANK ❑ 1 STEEURON ❑2 STAINLESS STEEL ❑D FIBERGLASS ❑1 STEEL CLAD WIRBEFQASS REINFORCED PLASTIC MATERIAL ❑5CONCRETE ❑6 POL VINYL CNLOROF ❑ 1 ALUMWW El 109%METHALOL COMPATIBLE FRP E]9 BRONZE ❑ 10 GALVANIZED STEEL ❑%UNKNOWN ❑99 OTHER C.INTERIOR ❑ I RUBBER LMED ❑2 ALKYD LINING -.-. ❑]EPOAYLINING ❑/PHENOLICLNNG LINING ❑ 5 GASSLWING ❑6 UNLINED I 1 E195 UNKNOWN ❑ IS EWING MATERIAL COMPATIBLE WITH IOD%METIMNOp ❑ YES ❑ NO EJ 99 OTHER D.CORROSION ❑ I POLYETHLENE Y/RAP ❑ 2 TAR ASPHALT ❑]VWYI wHAP ❑1 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATNOOIC PIgTECTON ❑91 NONE ❑95 UNKNOWN ❑%OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCIbN A U 2 PRESSURE A U ]GRAVITY A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALLED A U 2 000BLE WALLED A U ]LINED TRENCH A U %UNKNOWN A U 99 OTHER A U I SIEELPROALUMINUM A U 2 STAINLESS STEf1 A U ] POLYVINYL CHLORIDE IPVGT A U A FIBERGLASSPIPE C. MATERIAL A U S ALUMINUM A U 6 CONCRETE A U I STEEL CLAD W/FNP A U 8 1001 METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A AT 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY.A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUAL CHECK P S 2 INVENTORY RECONCIE1ATION P S ]VADOSE WELLS P S < ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S Z PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I ESTIMATED DATE LAST USEp IMO/YNI ESTIMATED OUANI IV OF ] WAS IANK FILLED WITH ' SUBtiIANCE HFMAININGIN INERT MATERIAL' GALLONS ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT APPLICANT'S NAME IPILINIEp A$IGNA IIIII, I 1' LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AAGENCYIITN FACILITY ID N TANK ID N :C:'I!RE.TCAL AGENCY FACILITY ID• APpppyED BY NAME PHONE N WITH AREA CODE PERMIT NUMBS ESUICHRR"- RMIT APPpOYAI GATE PERMIT EXPIRATION DATE CHECK PERMIT AMOUNT AYT. FEE CODE RECEIPT F 9q; FORMSO-].BRI THIS FORM MUST BE ACCOMPANIED BY A FACILITYZSITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM'A' HAS BEEN FILED 1 DATA PROCESSING COPY I