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I HIV K 1 Auw( PtRMIT APPLICATION INFr-TMATION COMPLETk EPARATE FORM WITH THE FOLLOWING INFO�,,M/ATION FOR EACH TANK- MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANCE OF INFORMATION I� ONE ITEM L_ VE CLOSED TANK ❑2 INTERIM PERMIT ❑/AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE E114 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: o 17 FARM TANK-YES NO I. TANKOESCRIPTION COMPLETE ALL ITEMS.IF UNKNOWN—SO SPECIFY 7 ' A OWNERS TANK IDN !7 to _? B. MANUFACTURED BY: C. YEAR INSTALLED 0. TANK CAPACITY IN GALLONS: H. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. ? A. ❑ I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. IV ❑ ❑CHEMICAL PRODUCT ❑ 1 OR I UNLEADED ❑2 LEADED E]3 DIESEL N F] ClI PRODUCT /GASAHOL ❑5 JET FUEL ❑6 AV01fTDN GAS ❑5 HAZARDOUS ❑M EMP ry 95 UNKNOWN ❑2 WASTE ❑ 1 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 C.A.S.N: KIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.R,C.6 D A TYPE OF ❑ 1 DOABLE WALLED ❑3 SINGLE WALLED NTH EXTERIOR LINER %UNKNOWN SYSTEM ❑2 SINGLE WALLED C11 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEL/NDN B.TANK El STAINLESS STEEL ❑3 FIBERGLASS ED STEEL COD W/FIBERGUSS REINFORCEDRASTIL a 'I MATERIAL ❑ 5 COFIOETE ❑6 POLYVINYL LILOROf ❑ 7 ALUMINUM ❑N 100%METHANOL.COMPATIBLE FFP ❑9 BRONZE ❑ 10 GALVANIZED STEEL %UNKNOWN ❑99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑2 ALKYOUNING ❑ J EPOKY LNNNG ❑1 PHENDIIC LIMNG LINING ❑5 LASS LINING ❑6 UNU ED I I ❑%UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE NTH 100h METMANOtT ❑YES ❑ NO ❑99 OTHER 0.CORROSION ❑ 1 POLYETME EWRAP ❑2 TAR OR ASPINLT ❑3 VINYL WRAP ❑1 FIBERGIASS{EINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑W 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 B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH AU 95 UNKNOWN -- A U "OTHER F MATERIAL A U I STEEL/IRON A U 2 STAINLESSSIEEI A U 3 POLYVINYLCHLORIDE(PVC) A U I FIBERGLASSPIPE A U 5 ALUMINUM A U 6 CONCRETF A U I STEEL CLAD W/FHP A U 9 GALVANUEO S-TLEL A U 95 UNKNOWN A U BIIMW METHANOL COMPATIBLE FHP A U 99 OTHER V. LEAK DETECTION SYSTEM ORCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUAL CHECK P S 2 INVENTOR/RECONCILIATION P S 3 VADOSE WELLS P S I ELECTRONIC MONITORP S S GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 5 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I ESOMATED GATE LAST USED IMO/YRIEESTIMAIE000ANTITYOF 1 WA$TANK FILLED WITH SUITS7ANCE REMAINING IN INERT MATERIAL' ❑YES ❑ No _j L _ GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,FS TRUE AND CORRECT APPLICANT'S NAME IPRINiF��IGN41 0/ E. J 1' b LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID N C LOCAL AGENCY FACILITY 10• APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER _- PERMIT APPROVAL DATE PERMIT EXPIRATION OATS _ CNECKN PER MIT AMOUNT SURCHARGE AMT. FEE CODE - RECEIITN BY. FORM 8p7-M1 THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HASBEENFILED DATA PROCESSING COPY