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I AIV K 1.0K <br /> %'C PERMIT APPLICATION INFOFNT TION <br /> p COMPLETE A RATE FORM WITH THE FOLLOWING INFORM N FOR EACH TANK. <br /> MARK ONLY ❑ I NEW PERMIT 7 RENEWAL PERMIT 5 CHANGE OF INFORMATION <br /> ONE ITEM ❑21NTERIM PERMIT IPERMANENiIY CLOSED TANK <br /> ❑6 AMENDEOPERMIT 6 TEMPORARY TANK CLOSURE ❑8 TANKREMOVED y1•7 F <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: F I '�1 <br /> FARMTANK-YES❑ NO <br /> I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY <br /> A OWNERS TANK IDE I o <br /> B. MANUFACTURED BY: �, �. - <br /> C.YEAR INSTALLED rat 58 D. TANK CAPACITY IN GALLONS: <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM O. A <br /> A. � 40TOR VEHICLE FUEL ❑2PETROLEUM TV <br /> B. C. ❑ I UNLEADED 2 LEADED J DIESEL N <br /> ❑ J CHEMICAL PROOLKT ❑6 OIL Q ODUCT ❑K GASAHOL ❑5 JET FUEL <br /> ❑ 5 HAZARDOUS ❑6 AVIATION GAS <br /> ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ T METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) <br /> 0. IF NOT MOTOR VEHICLE FUEL ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED 6 C.A.S.N <br /> C.A.S.E. <br /> .111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,6,C.6 D <br /> rA-TYPE F ❑ I DOUBLE WALLED ❑J SINGLE WALLED WITH EXTERIOR LINER ❑9S U K(NOM <br /> M ❑2 SNGLE WAILEDA SECONOMYCONTAINMENT ❑9I OTHER <br /> ❑ I STEEUIRON ❑2 STAALE55STEEL ❑J FIBERGLASS ❑VSTEEL CUD W/FIBERGLASS BEVfORCEO PLASTIC <br /> IAL ❑5 COfICRETE ❑6 POIYVNYLCKOREIf ❑ I ALUMINUM ❑8 100%M TRV40L COWATIBLE FRP <br /> ❑9 BRONZE ❑ 10 GALVAM2EDSTEEI ❑ 95 UNKNOWN ❑99 OTHER <br /> C.INTERIOR ❑ I RUBBER LINED ❑2 ALKYD LINING ❑ J EPDXY UNINi 1 PHENOLIC LINING <br /> LINING ❑5 GLASS LINING ❑6 MINED 1 1 ❑95 UNKNOWN <br /> ❑ IS UNNG MATEWAL COMPATIBLE WITH LOOM METHANOL, ❑YES ❑ NO ❑29 OTHER <br /> 0.CORROSION ❑ I POLYETHENE WRAP ❑2 TAR OR A$NALI ❑J VINYL WRAP A RBFAGIA$S REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATH O0CPHOTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A SYSTEM TYPE A U 13UCTIOFI A U 2 PRESSURE A U O GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U J LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> A U I STEEL/IRON A U 2 SIAINLESSSIEEL A U J POLYVINYLCHLORIDE(PVC) A U A FIBERGLASSPIPE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRE If A U I STEEL CLAD W/FNP <br /> A U 9 GALVANIIEDSTLEL A U 95 UNKNOWN A U 99 OTHER A U BLOOM Mf THANOL COMPATIBLE FNP <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY.A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P 5 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 5 9 VADOSE WELLS P S A ELECTRONIC MONITOR P S S GROUNDWATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 2 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN <br /> I 5 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> I ESTIMATED DATE LAST USED IMO/YRI ? ESTIMATED QUANTITY Of <br /> ] WASIANKEILLEOWITH <br /> SIlB51gNCE REMAINING IN INERT MATERIAL, ❑YES ❑ No <br /> GALLONS <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PIRNIFD K%IGNA11.111T I <br /> DA,E!•. <br /> LOCAL AGENCY USE ONLY <br /> COUNTY A JURISDICTION E AGENCY, <br /> FACILITY ID A <br /> TANK IDE <br /> CURRENT LOCAL AGENCY FACILITY 10 E APPROVED BY NAME <br /> L� / <br /> PHONE Y WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EEMRATIOH DATE <br /> CHECK E PERMIT AMOUNT SUgCHMGE AYT. FEE CODE RECEIPT F <br /> BY: 3 6 � <br /> FORMBI]-T-BBI THIS FORM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HASSEENRLED <br /> DATA PROCESSING COPY REC, I <br />