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I AIVK IANK PERMIT APPLICATION INFO""MATION y, COMPLETE '.PARATE FORM WITH THE FOLLOWING INFOI`.,,TION FOR EACH TANK. 1d,. a MARK ONLY ❑ 1 NEW PERMIT ❑J RENEWAL PERMIT5 CHANGE OF INFORMATION I� ONE ITEM ❑ L��jPEflMANENTLY CLOSED TANK ❑2 INTERIM PERMIT ❑ N AMENDED PERMIT ❑6 TEMPOMMTANK CLOSURE B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: _ �- AA7 FARM TANK-YES NO ❑ 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY I;'o A OWNERS TANK ION C. YEAR INSTALLED B. MANUFACTURED BY: D. TANK CAPACITY IN GALLONS: QCy, 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 N ❑O CHEMICAL PRODUCT ❑1 OIL C:107GASAHOL DED ❑2 LEADED ❑ J DIESEL❑ 1 PRODUCT ❑S JET FUEL ❑6 AVIATION GAS ❑ 5HAZARDOUS ❑ B0 EMPTY U 95 UNKNOWN ❑2 WASTE NOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED S C.A,S.N GAS.N. .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C.A D A TYPE OF ❑ 1 DOUBLE WALLED ❑ J SINGLE WALLED NTH EXTERIOR LINER ❑%UNKNOWN SYSTEM ❑2 SINGLE WAILED ❑1 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEL/YpN 2P fNSSTEL J FIBERGLASS TANK 1STEELCIAOW/FBERGIASSRENFORUOPIASTC ;I MATERIAL ❑5CONCRETE ❑6 POLYVINYL CHLORIDE ❑ I ALUMWIM ❑6 IDD%METHANOL COMPATIBLE FRP ❑9 BR04ZE ❑ 10 GALVANIZEDSTEEI ❑ %UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUSKRU615 ❑2 ALKYD LINING ❑ J EPDXY LIVING ❑1 PIENOLKLMNG LINING ❑5 GLASS MING ❑6 UNLINED I I ❑%UN(NOWN ❑ IS LWING MATERIAL COMPATIBLE NTN IOD%METHANDLT ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHENE WMP El2 TAR OR ASPHALT .._.._ElJ VWYL WRAP ❑T FIBERGLASS REINFORCED RASTC PROTECTION 5 CATHCClCPROTECTKNI ❑ 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 J GRAVITY A U N OTHER ' B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOABLE WALLED A U l LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U ? STAINLESSSTEEI A U O POLYVINYL CHLORIDE(PVC) A U A FISERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U I STEEL CLAD W/FHP A U BIIKIK METHANOL COMPAIIRLE FNP A U 9 GALVANIZEDSTLEL 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. i P 5 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 5 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P 5 6 PRECISION TESTING P S ?PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1 fSTIMgTEO DATE LAST USED IMO/Yfl) ESTIMATFDOUANTIlYOF 7 VIAS TANK ERLED WiTn I ' SURSIANCE REMAINING IN INERT MATERIAL, ❑YES [] NO GALLONS 1 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT APPLICANT S NAME LPRINTFD A SIGMAIUIIT D/5 E�•. J LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N IL17Y 1 TANK ID N -3 __ 3. 3 - / C ENT LOCAL AGENCY FACILITY ID N APPROVEDBYNAME PHONE N WITH AREA CODE PERMIT NUMBE --- _ -- PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE -- RECEN'TS BY: k T71 FORM B pTae) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' NAS BEEN FILEO I DATA PROCESSING COPY `so