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FORM 'B': UN" -RGROUND STORAGE TANK Pr ')GRAM ra%�J,,�:� TAIVK PERMIT APPLICATION INFOFtwfAT10N rAN E': 'a C PLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY 1'NEW PERMIT ❑3 RENEWALPERMIT CY5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑O AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED } FACILITY/SITE NAME WHERE TAI4K IS INSTALLED: Exxon RAS # 7- FARM TANK-YES❑ NO ❑X I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OYINERS TANK IDR B. MANUFACTURED BY: C. YEAR INSTALLED 1 D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A-1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A ® 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ® 1 UNLEADED ❑2 LEADED E]3 DIESEL ❑3 CHEMICAL PRODUCT ❑ K OIL ® i PRODUCT ❑J GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN REM.D.BELOW) 0. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED d C A.S.R Kill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.iD A.TYPE OF ❑ I DOUSE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑ 95 UNKNOWN SYSTEM ®2 SINGLE WALLED ❑I SECONDARYCONTNNNIENT ❑ 99 OTHER ® 1 STEELi a ❑2 STAINLESS STEEL ❑3 F13Ef AJM ❑ /STEEL OUDW/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑6 TOM METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ IO GALVANIZED STEEL ❑95 UNKNOWN ❑93 OTHER ❑ C. INTERIOR RI PUBB UNED ❑2 ALKYD UNING ❑3 EPDXY UNING ❑/PHENGJCLMING UNING ❑5 CUSS LINING ®6 UNLINED ❑95 UNKNOWN ❑IS UNING MATERIALCOMPAT18LE MTH I OD%METHANOL? [:]YES ❑ NO ❑97 OTHER D.CORROSION ❑1 POLYETHLENEWRAP ❑2 TARORASNMLT ❑3 YOWLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ®5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND.BOTH IFAPPLICABLE A SYSTEM TYPE, A U I SUCTK)N A(p) 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A © I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U %OTHER AQ 1 STEEL-HROI 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 STEELCLAD 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 B I VISUAL CHECK ►O S 2 INVENTORY RECONCILIATION P E 3 VADOSE WELLS P f A ELECTRONIC MONITOR P 3 5 GROUND WATER MONITORING WELLS (-*)6 PRECISION TESTING P i 7 PRESSURE TESTING P f 91 NONE P B 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATEDOUANTITY OF A WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL7 ❑YES [:]NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJUFy4ANO 1p THE ST OF MY KNOWLEDGE.I§TRUE AND CORRECT. APPLICANT'S NARE(PHNTf�`IIGNM pfE) DATE 1177 JJ �I�Vr1ICC 11 CC►►TT i 7 9/ LOCAL AGENCY USE ONLY CCUN..T A JURISDICTION t AGENCY E FACILITY IDI TANK ID B 7 � = F r n- L CURRENT LOCAL AGENCY FACILITY ID EAPPRDYED BY NAME PHONE P WITH MEA CODE PERMITNUYBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK• PERMIT AMOUNT SURCHMGE AIT. I FEE CODE I RECEIPT F - BY: FORM B(3-7-BB) THIS FORM MUST BE ACCOM' -.D BY A FACIU7Y/STTE APPLICATION, FORM 'A',UNL CURRENT FORMA' HAS BEEN FILED .... DATA PROCESSING COPY ...r'