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ka FORM `E31: UN -RGROUND STORAGE TANK P' -)GRAMTAT7K PERMIT APPLICATION INFOR19ATION ANCO PLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY 1'NEW PERMIT ❑3 RENEWALPERMIT CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑K AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 3 FACILITY/SITE NAME WHERE TANK IS INSTALLED: Exxon RAS # 7- FARMTANK-YES❑ NO ❑X 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A OWNERS TANK 10 X B. MANUFACTURED BY: C. YEAR INSTALLED I .j 1 D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(A7),IS NOT MARKED,COMPLETE ITEM D. A ❑ 1 MOTOR VEHICLE FUEL ® 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ K OIL ❑ 1 PRODUCT ❑K GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY E]95 UNKNOWN ®2 WASTE ❑ 7 METHANOL ® 99 OTHER(DESCRIBE IN REM.O BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 CAS.# ` C A.S.#: KI11. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B.C.i D A.TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED MTH MERKR LINER ❑%UNKNOWN SYSTEM �2 SINGLE WALLED ❑1 SECONDARICONTANVENT ❑99 OTHER ®1 STEEL om ❑2 STAINLESS STEEL ❑3 RKIRGUSS ❑/STEEL CUD W/RBERGUSS REWfORLED PLASTIC S.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORDE ❑T ALUMONM ❑8 100%METHANDL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑%LII7KNDY/N ❑99 OTHER C. INTERIOR F1I RUBEERLINED ❑ 2AMD LINING ❑3 EPOAYUNING ❑ 1 PHENUJCUNING LINING F-15 GLASS LIN!NG ®6 UNUNFD ❑%UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%MEDIHOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENEWRAP [j2 TAR ORASPHALT ❑3 RIM WRAP ❑4 FIBERGLASS REINFORCED PLASTIC ^ PROTECTION (1 5 CATHODIC PROTECTION ❑91 NONE ❑%uNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND.BOTH IF APPLICABLE A SYSTEM TYPE A ,�Upp,, 1 SUCTION A U 2 PRESSURE A(3) 3 GRAVITY A U 99 OTHER v B. CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUSLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTRER A Cud 1 STEELJWOK A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U K FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL C AD W/FRP A U B 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 S I VISUAL CHECK Q S 2 INVENTORY RECONCILIATION P $ 3 VADOSE WELLS P S #ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 5 95 UNKNOWN P 6 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF S WAS TANK FILLED WITH SUBSTANCE REMAINING IN AllON9 INERT MATERIAL? [:]YES ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY TH F) ST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S Nlff(PgNTMeVfR") DATE FITC 7 L / 11 LOCAL AGENCY USE ONLY c"N", J JURISDICTION# AGENCY P FACILITY ID• TANK ID B 9! = 2 CURRENT LOCAL AGENC3' IT/FACIL10 E APPROVED By NAME PHONE P WITH AREA CODE PER NUMBER 1 '7 PERMITA►PROVKDATE PERMIT EXPIRATION DATE CHECK• PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(3-7AB) THIS FORM MUST BE ACCOM' °D BY A FACILITYMTE APPUCAn0K FORM 'A',UNC '.CURRENT FORMA' HAS BEEN FRED .�,. DATA PROCESSING COPY ...r 11