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<. 1 ; FORh4 'E3': UN ":RGROUND STORAGE TANK P' (GRAM TNKQ TAWK PERMIT APPLICATION INFOR3CIATION Cq4PLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. '��• MARK ONLY 1'NEW PERMIT ❑3 RENEWAL PERMIT 45 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2INTERIM PERMIT ❑ A AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 0 TANK REMOVED J I FACILITY/SITE NAME WHERE TANK IS INSTALLED: Exxon RAS # 7- FARM TANK-YES❑ NO 91 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A OWNERS TANK IDR B. MANUFACTURED BY: C. YEAR INSTALLED G D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(At),15 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A ® 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. ® 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT F-1I OIL ® 1 PRODUCT ❑4 GASOHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN REM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 C A.S.8 CAS.I: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOT(A.8,C,A D A.TYPE OF ❑ 1 DOUG E WALLED ❑3 SINGLE WALLED WITH EYUM UNER ❑%UNKNOYM SYSTEM 2 SINGLE WALLED ❑I SECONDARY CONTAINMENT ❑99 OTHER ©1 STEELARON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑1 STEROL D W/FIBERGLASS REINFOPCED PLASTIC B.TANK ❑5 CONCRETE E]6 POLYNNYLCHLOA9DE [:]7 ALUMINUM ❑8100%METHANOLCOMFATIBLEFRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUB6ERUNED ❑2 ALODUNING ❑3 EPOYY LINING ❑A PHENOUCUNING C.INTERIOR LINING ❑ 5 GLASS LINING ®6 UNLINED El %UNKNOWN ❑B LINING MATERIAL COMPATIBLE WITH 1009.MMW40LI ❑YES ❑NO ❑99 OTHER D.CORROSION ❑1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VNYL WRAP ❑1 FIBERGLASS REINFORCED PLASTIC PROTECTION ®5 CATHODIC PROTECTION ❑91 NONE ❑95 UW40WN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A 1 STEEL7IROW A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U , FIBERGLASS PIPE C MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAO W/FRP A U 8 1 DO%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 3 1 VISUAL CHECK o B 2 INVENTORY RECONCILIATION P 3 3 VADOSE WELLS P 3 I ELECTRONIC MONITOR P 3 5 GROUND WATER MONITORING WELLS P 6 PRECISION TESTING P 3 7 PRESSURE TESTING P 3 91 NONE P 3 95 UNKNOWN P 3 99 OTHER Vi. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF I WAS TANK FILLED WITH SUBSTANCE REMAINING IN GONS INERT MATERIAL? ❑YES [:]NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY A HE iWTOFmy KNOWLEDGE.I TRUE AND CORRECT. APPUCANTB NQEPjIN ft2fRRE) DATE / 79/ LOCAL AGENCY USE ONLY z 41 court:T O JURISDICTION* AGENCY F FACILITY ID 3 TANK ID 3 CURRENT L AGENCY F CILITY 10I APPROVED BY NAME PHONE F WRII AREA CODE �O PERMM NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CNECKB PERMIT AMOUNT SURCHARGE AMT, FEE CODE RECEIPTI BT: f/ FORM B(3-7-86) THIS FORM MUST BE ACCOI ED BY A FACILITYMM APPLICATION, FORM 'A',UN' A CURRENT FORMA' HAS BEEN FILED .� DATA PROCESSING COPY (^