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1 All& IAi4K PtkMIT APPLICATION INFORMATION �, <br /> COMPLETE A SF UTE FORM WITH THE FOLLOWING INFORMA 4 FOR EACH TANK. •�iO•a <br /> MARK ONLY ❑ I "PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 1 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED <br /> FACILITYTSITE NAME WHERE TANK IS INSTALLED; j' ri 0t:? FARMTANK-YESpr NO ❑ <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 0 <br /> A OWNERS TANK IDN B. MANUFACTURED BY: <br /> C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS' <br /> 11. TANK CONTENTS IF(A.1).IS MARKED,COMPLETE ITEM C. (A.1),IS NOT MARKED,COMPLETE ITEM A <br /> r N <br /> A. I MOTOR VEHICLE FUEL ❑2 PETROLEUMS / C. ❑ I UNLEADED 2 LEADED ❑ 3 DIESEL N <br /> ❑ 3 CHEMICAL PRODUCT ❑/GL W,' PRODUCT ❑ 1 GASAHOL ❑S JET FUEL ❑6 AVIATION GAS <br /> ❑5 HAZARDOUS ❑ W EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑99 OTHER IDEBCRUBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED A C A.S.N C.A.S.N. <br /> .111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B•C,E D <br /> A TYPE OF ❑ 1 DOUSE WAILED ❑3 SINGLE WALLED WITH OTEBON LINER ❑95 UNKNOWN . <br /> SYSTEM ❑2 SINGLE WAILED ❑1 SECONDWNCONTAINMENT ❑99 OTHER <br /> ❑ <br /> e.TANK 1 STEEUREW ❑2 STAINESSSTEEt E]3 FIBERGLASS E]1 STEEL CLAD W/FIBEBGLASSIFO ORCEO PWSTIC <br /> 'i MATERIAL ❑5 CONCMTE ❑6 POLYVINYL CHLORIDE ❑ 1 ALUMINUM ❑I IOD%MEIIMNDL Cg1PA1IBLE RP <br /> ❑9 BRONZE ❑ 10 GALVANZEDSTEEI ❑95 UNKNOWN ❑99 OTHER <br /> C. INTERIOR ❑ I RULIBERUNED ❑2 AMC EWING ---... ❑ 3 EPDXY LINING ❑1 PHENJUCLINNG <br /> LINING ❑5 CLASS LINING ❑6 MAIMED 1 1 ❑95 UNKNOWN <br /> ❑ B LNNNG MATERIAL COMPATIBLE WITH 100%METH Dt, ❑YES ❑ NO ❑%OTHER <br /> D. CORROSION ❑ 1 POLYETHLD EWRAP ❑2 TARORASRMLT ❑3 VNRL DUMP ❑1 fBEBGUS58EINOgCEO PUSTO <br /> PROTECTION ❑ 5 CATHODIC PBOTECTON ❑ 91 NONE ❑95 UNKNOWN ❑99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY <br /> A U 99 OTHER <br /> B.CONSTRUCTION A U I SINGLE WALLED A U 2 BCUSLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> A U I STEEL/IRON A U 2 STAINLESSSIEEL A U 3 POLYVINYL CHLORIDE A U A FIBERGLASS PIPE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCREil. A U ) STEEL CUD W/FNP <br /> A U 9 GALVANIIEO STEEL A U 95 UNKNOWN A U B 100%METHANOL COMPATIBLE FHP <br /> A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> i <br /> P S I VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S A ELECTRONIC MONITOR P S $GROUND WATER MONITGflING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESS, TESTING <br /> 1 5 91 NONE P S 95 UNKNOWN P S 99 DTHEfl <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> I ESTIMATED GATE LAST USED(MO/YRI 2 <br /> ESTIMATED OUANTIIV OF 1 WA$TANK FILLED WITH <br /> SUBSI ANCE REMAINING IN INERT WTFRIALI <br /> GALLONS ❑YES ❑NU <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED A S1f.NA1111111 <br /> DA/E!•. <br /> 1 I <br /> LOCAL AGENCY USE ONLY <br /> COUNTY E JURISDICTION M AGENCY N <br /> ntilI.PFWBy TANK ID x <br /> x '- <br /> APPROVED BY NAPE PHONE•WITH AREA CODE <br /> - _-- PERMIT APPROVAL DATE --- <br /> PERMIT ENNgAT10M DATE <br /> T SURCHARGE AYT. <br /> FEE CODE RECEIPT• <br /> FOTMB(3.7-86) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM �A',UNLESSACURRENT fORM'A' NAS BEEN FILED <br /> DATA PROCESSING COPY <br /> .�ILA�'YSr:1:IY"�" Ilil F•r,•ay-r <br />