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I ARK I "NK Pt:HMIT APPLICATION INFO^MATION �,� : COMPLETE PARATE FORM WITH THEVFI FOLLOWING INFOION FOR EACH TANK. i 1 MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT ❑ ONE ITEM 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ❑ 2 INTERIMPERMIT ❑A AMENDEOPERMIT (y ❑6 TEMPORARY TANK CLOSURE �TANK REMOVED © —/ FACILITY/SITE NAME WHERE TANK IS INSTALLED: r-'462a,t FARMTANK-YES NO ❑ _> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A OWNERS TANK ID M o G YEAR INSTALLED B. MANUFACTURED BY: D. TANK CAPAGTY IN GALLONS: II. TANK CONTENTS IF(A.1).IS MARKED,COMPLETE ITEM C.IF(A T),IS NOT MARKED,COMPLETE ITEM D. A A ❑ I MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. I D UNLEAED ZD ❑7 CHEMICAL PRODUCT ❑A OIL ❑ ❑2 LEADED ❑7 DIESEL N ❑ I PRODUCT ❑A GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5,HAZARDOUS ❑10 EMPTY � ❑5 UNKNOWN 2 WASTE ❑ 7 METHANOL E]99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 C.A.S.M C.A.S.E. K111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,A D A TYPE OF ❑ 1 DOUBLE WALLED 0 SINGLE WALLED WttN EXTERIOR LINER %UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑A SECUpAMCONFAWMENT ❑99 OTHER P B.TANK ❑ I STEEL/VON ❑2 STAINLESS STEEL ❑J FIBERGLASS E]1 STEEL CLAD W/FBERGIASS RENEORCFD PLASTIC MATERIAL ❑ 5 CONCRETE ❑6 POLYVWYLCILORDf ❑ /ALUMINUM ❑I IOD:METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVAMZEDSTEN ❑%UNKNOWN ❑99 OTHER ❑ C. INTERIOR 1 RIBBER LINED 2 ALKYO LINING .... ❑ J EPDXY LINING ❑1 PHENOCUM G ❑ LINING ❑5 GLASS LINING 6 UMINED I ❑%UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WHIN IW►METHANOL 1 ❑YES ❑NO E]99 OTHER D. CORROSION ❑ I POLYETHLFNE WRAP ❑ 2--TAR ❑J VINYL WRAP ❑1 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A If ABOVE GROUNU, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 9 GRAVITY _ A U %OTHER I B. CONSTRUCTION A U I SINGLE WALLED_ A U 2 DOABLE WALLED A U 9 LINED TRENCH A U 95 UNKNOWN A Y 99 OTHER A U I STEEL/IRON A U 2 STAINLESSSIFFI A U I POLYVINYL CHLORIDE(PVC) A U A FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 GONCHE If A U ) STEEL CLAD W/FNP A U 9 GALVANIZED STLEL A U 95 UNKNOWN A U 8 IIKI%METHAHOL COMPp11BLE fHP A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FORPRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. i P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S S VADOSE WELLS P S K ELECTRONIC MONITOR P S 5 GROUND W P S 6 PRECISION TESTING P S I PRESSURE TESTING ATER MONITORING WELL P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I ESTIMATED DATE LAST USED IMO/VRI 2 ESTIMATED OUANTITYOF 1 WAS TANK 4ILL ED WITH SUBSI ANCF REMAINING IN GALLONS INERT MATERIA1.1 ❑YES ❑ NO� THIS FORM HAS BEEN COMPLETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT [APPLICANT'S NAME(PRINI FD A$IGNn 1 UHF 1 OA5 E. LOCAL AGENCY USE ONLY I COUNTY E JURISDICTION E AGENCY F FACILITY ID f TANK ID Y CURRENT LOCAL AGENCY FACILITY 10• APPROVED BY NAPE PHONE I WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE - - CHECKK PERMIT AMOUNT SURCHARGE AVT. EEE CODE - RECEIR F FORM B W-7.W) THIS FORM MUST BE ACCOMPANIED BY A FACILEYY(SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM•A• HAS BEEN FILED ---- _ _. DATA PROCESSING COPY :'YTOti:wKIF'$�i1:l:;i.1rt�'w'�GY183'P,:Ltiit:I.+.JIIaA:ncr.1...5-:,MsA.,:.w..