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LAlt Vt (:ACIPVRNf WAMR RESOURCES CONTR( �OARD FORM 'S'• UNO..IGROUND STORAGE TANK PR`,6RAM TANIC� / TANK PERMIT APPLICATION, INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION EOR EACH TAN OIF, Q MARK ONLY ❑1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION [2�PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/BITE KAME WHERE TANK 18 INSTALLED. T 0,615 737,6- FARM TANK-YES❑ NO 1. TANK DESCRIPTIONCOMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY Io A. OWNERS TANK IDR ON"OWN B. MANUFACTURED BY: VY C.YEAR INSTALLED UNKNOWN D. TANK CAPACITY IN GALLONS: 1 000 CIAL If. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,cqMPLETE ITEM D. N A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑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&CA.S.N CAS.8: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,B D A TYPE OF ❑ 1 DOUG EWMIE1 ❑3 SINGLE WALLED WITH EXTEROR UNER ❑95 uN(NOWN SYSTEM 2'$TIGLEWAUED ❑4 SECONDARYGONTNNMENT ❑99 OTNER �'ruffil9XN ❑25'TNNLEfiSSTEB. ❑3 FIBERGLASS ❑4 MR CUA W/FSERGLASS REINFORCED RASVC B. MATERIAL ❑5 CONWTE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 180%METHANOLCOMPARBLERIP ❑9 BRONZE ❑ 10 GALVANIZEDSIFE ❑95 UNKNOWN ❑99 OTHER 'C.INTERIOR ❑ 1 RUBBERUlE) ❑2 MXYD LINING ❑3 EPDXY UNING ❑4 NNOWUNING LINING ❑5 GUM UMNG Ga'EUAINED ❑95 own ❑ISLNNGMATERALCOMPATIBLEWIIH180%MERWIOL? ❑YES ❑NO 99 OTHER D.CORROSION ❑1 PoLYE7HLENEWNAP ❑2 TM OR ASPHALT ❑3 VNYLWRAP ❑4 RBERGIACSRO FORC®PIASTIC PROTECTION ❑5 CAT-MIC 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 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 RBERGLASSPIPE C.MATERIAL A U $ALUMINUM A U B CONCRETE A U 7 STEELCIAD W/FRP A U 8 100%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 6 / VISUAL CHECK P S 2 INVENTOR/RECONGUATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 6 6 PREGSION TESTING P 6 7 PRESSURETESTING P 9/ NONE- • 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE UST USED(MO/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN,,,,�D �LDNS INERT MATERIAL? ❑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(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY k JURISDICTION k AGENCY k FACILITY 10 A TANK IDS 1-3124- F50- lo CURB NT LOCAL AGENCY ACILITY ID X APPROV D BY NAME n PHONE I WTTH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PER IT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECENT0 BY. FORM 8(3/-95) THIS FORM MUST BE ACCOMPANIEL-. A FACILTTY/SITE APPLICATION, FORM 'A',UNLESS A .ENT FORMA HAS BEEN FILED DATA PROCESSING COPY