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TANK TANK�'RMITAPPLICATION INFORMA JN COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATIO R EACH TANK. MARK ONLY 4WMNEW PERMIT ❑3RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ IPERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERNA PERMIT ❑ A AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED; U FARM TANK-YES❑ NO '7 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 10 A. OWNERS TANK IDN _ _ B. MANUFACTURED BY: .0 C. YEAR INSTALLED / 9�'CJG ' D. TANK CAPACITY IN GALLONS: V,DDD 11. TANK CPNTENTS IF(A.1).IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE REM O. (V A. I MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED DIESEL `�- ❑3 CHEMICAL PRODUCT ❑A OIL �mODUCT ❑1 GASANL ❑5 JET FUEL ❑6 AVIATION GAS N ❑ 5 HAZARDOUS ❑60 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 A C.A.S.N CA.S.N. ■111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,8,C,A D A.TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LNER 95 MKNOYM SYSTEM ❑2 SINGLE WILLED ❑A SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEUN ❑2 STAINLESS STEEL ❑3 RBEWAASS ❑1 STEEL CUD W/FIBERGLASS RENNORCED"TIC B MATERIAL Ng❑5 CONCRETE ❑6 POLYVINYL CILORDI ❑ I ALUMINUM ❑S 100%METHANOL COMMITTEE RIP t ❑9 BRONZE ❑ 10 GALVANIZED STER ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑Z kOOLINI% ❑3 FPDXYUNING ❑1 PHENOLOUMNG LINING ❑ 5 GLASS LINING ❑6 LNURED 1 ❑95 UWNOWN ❑ IS LIKING MATERIAL COMPATIBLE WITH IWMI METHANOL' ❑YES ❑NO ❑ 99 OTHER D.CORROSION ❑ I POLYETHIENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑A 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 IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLWINYLCHLORIDEIPVC) A U A FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CUD W/FRP A U S IAUWMETHANOLCOMPATIBLE 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 P S 2 INVENTORY RECONCILIATION • 5 3 VADOSE WELLS P S A ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P 5 7 PRESSURE TESTING • S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I ESTIMATED DATE LAST USED(MO/YRI 2 ESTIMATED QUANTITY OF 3 WAS TANK FILLEDTH PA SUBSTANCE REMAINING IN GALLONS 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 6 SIGNATURE I D75 E / A P LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY M FACILITY ID N TANK ID N = = jdQ I /T5 gL 3 DD CURRENT LOCA GENCY FACILITY ID F A"ROVIDTABY NAME PHONE N WITH AREA CODE PERMIT NUMBER PER WT A"ROVAL DATE RMIT EKRRATION DATE CHECK• PERMIT wMOUXT SURCHARGE AMT. FEE CODE RECEIPT BY: FORM B 0 7 BB) THIS FORM MUST BE ACCOMPANIED BY A FACILRY/SI1E APPLICATION, FORM'A�.UNLESS A CURRENT FORMA HAS BEEN FILED i __ DATA PROCESSING COPY