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I ANK IANK PERMIT APPLICATION INFOPAAATION COMPLETE b ,?ABATE FORM WITH THE FOLLOWING INFOR'�ION FOR EACH TANK MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 'CMAFKIE OF INFORMATION ONE ITEM LlJ 2 INTERIM PERAIT /AMENDED PERMIT ❑ T PERMANENTLY CLOSED TANK 1:16 TEMPORARY TANK CLOSURE ❑B TANK REMOVED 2 FACILITY/SITE NAME WHERE TANK IS INSTALLED. —A$O SPECIFY FARM TANK•YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN— '� A OWNERS TANK ID K 5 B. MANUFACTURED BY: 4. I O C. YEAR INSTALLED 1q7q D. TANK CAPAGTY IN GALLONS: I 2/o p0 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM M A A. I MOTOR VEHICLE FUEL ❑2 PETROLEUM S. C. v ❑ 1 UNLEADED ❑2 LEAPED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑/OIL �TT ❑1 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS N ❑5 HAZARDOUS ❑So EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ T METHANOL ❑99 OTHER(DESCRIBE IN ITEM D•BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED IS C.A.S.M CAS.K. RIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOIL A.B,C,i D A TYPE OF r�21WG WALLED ROLE WALLED MIN EKTEROR LNER 02 UNKNOWN SYSTEM WALLED ❑1 SECONOMq DOITNNMENT ❑99 DIMER ON ❑2 STAINLESS STEEL ❑3 FIBERGLASS 1 STEEL CLAD W/FBEIIGIASSRENWRCEDRASTK:B. TANK ❑MATERIAL TE ❑6POLYVINYL CHLOEDE ❑ 1 ALUMINUM ❑B 100%METHANOLCOWATIBI EFRP 10 GALVANIZED STEU ❑95 UNKNOWN ❑99 OTHER C. INTERIOR I RIBSEHLNED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑1 PHENOLK:LNING LINING ❑5 GUSSLNNG ❑6 UNLINED I I �NOKN ❑ IS LUNG MATERIAL COMPATIBLE WITH 100%METHANOL ❑YES ❑NO ❑N OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TAR OR ASPHMT _8��- -YINYL ❑1 FIBERGLASS FENFORCFO PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER --- IV- PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND,BOTH IFAPPLICABLE A SYSTEM TYPE A I SUCTION A U 2 PRESSURE I A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U %UNKNOWN A U 99 OTHER C. MATERIAL A 0 STEELARON A U 2 STAINLESSSIEEI A U 3 POLYVINYL CHLORIDE IPVCI A U K FIBERGLASSPIPE A U 5 ALUMINUM A U 6 CONCRETE A U STEEL CLAD W/FRP A U 6 100%METXANOI COMPATIBLE FNP A U 9 GQYAN1IED$ITEM A U 95 UNKNOWN A U 99 9 DTXER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY.OR S FOR SECONDARY.A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. {yam P S I VISUAL CHECK ?5IS 2 INVENTOR'RECONCILIATION P S 3 VADOSE WELLS P S 3 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P 6 PRECISION TESTING PP s 1 PRESSURE TESTING P 5 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE E77777--- ESTIMATED DATE LAST USED IMO/YRI ESIIMATEDOLUNTIIYOF �—SUBSTANCE REMAINING IN 3 WAS TANK ELLLED WITH -� __ GALLONS INERT MATERIKI ❑YES ❑ND THIS FORM HAS BEEN COMPLETE!)UNDER PENALTY Uf PERJURY.AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRIN1 FD A SCANA 1 LINE I DD.E!•. LOCAL AGENCY USE ONLY COUNTY• JURISDICTION E AGENCY FACILITY IDE TANK ID E `,,___E EE=/ CURRENT LOCAIL AGENCY FACILITY to. APPROVED BY NAME PNONE I WITN AREA CODE vERMIT NUMBER PERMIT APPgpyAl PATE PERMIT ERPIgAT10N DATE CHECK• PERYIT AMOUXT SURCHARGE AMT. FEE CODE RECEIPT e FORM B 13 7 m1 THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA` MAS BEEN FILED DATA PROCESSING COPY _ ! L� TITER / 'da.... ..:r•. r....;..wSI . 'W„'Di6ATiF..vrtL7 wARPti�BD>`P:6tiI:.11rtxe:nu.rsy..a.e.., ;,...,.�say. ..._::,.,.... ....�_.....,..•..-._.-.____ _. 4Ei::0 :ATJ)y;;i17».•::i!iTiiWA)�Pr6m:=:1.- -"�- u.. __ ._ IV \FORM 8(6.2e,SB�.ONIB FORM MUST BE ACCOMPANIES A FACILITY/SN ,UNLESS E APPLICATION, FORM 'A' A — TRENT FORMA HASBEENFILED \ cwCJ �{J DATA PROCFSSIMr• CO.V