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I HIV K I AnK PtRMIT APPLICATION INFORVATION COMPLETE A S RATE FORM WITH THE FOLLOWING INF MA../N FOR EACH TANK, '".,• , MARK ONLY ❑ I NEW PERMIT ❑7 RENEWAL PERMIT 44 E OF INFORMATION ❑ T ANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ E AMENDEOPERMIT 6 TEMPORAM TANK CLOSURE TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 7 tow - FARM TANK-YES O ❑ _> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY to A OWNERS TANK IDM B. MANUFACTURED BY: O. YEAR INSTALLED D TANK CAPAGTY IN GALLONS �"ld i/� 11. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(Al),IS OT MARKED,COMPLETE ITEM O. A N A. UP MOTOR VEHICLE FUEL ❑2 PETROLEUM R. C. I UNLEADED IQ4WTflEADED 7 DIESEL ❑O CHEMICAL PRODUCT ❑ A OILN 1 PRODUCT ❑A GASAf10L ❑5 JET FUEL ❑fi AVIATION GAS ❑5 HAZARDOUS ❑ BD EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ T METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) O. IF NOT MOTOR VEHICLE FUEL ENTER NAME OF HAZARDOUS SUBSTANCE STORED A C.A S.E CA S M. -111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B,C.A0 A TYPE OF ❑ I R(E WALLED ❑7 SINGLE WALLED NTH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 22 SINGLE WALLED 1 SECONDARY CONTAINMENT El 99 c BNI STEEL/EON El2 STAINLESS STEEL 7 FIBERGLASS ❑1 STEEL CUD WZFVERGIASS REINFORCEDKSATIC ? YATERIAI E]5 CONCETE ❑6 POLYVINYLCKORO ❑ 1 ALUMINUM ❑B)ODE METHANOL COMPATIBLE FIP 0 9 BRONZE 10 GALVANIZED SEED ❑95 UNKNOWN 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING - ❑7 EPDXY LINING ❑1 PHE CLWING LINING ❑ 5 CLASS UMW ❑6 UNLINED I I L�"`"^^`yWN ❑IS LINING MATERIAL COMPATIBLE WITH IM METHANOL, ❑YES ❑NO LL❑��999"OTHER D. CORROSION ❑ 1 POLYETNLENE WRAP ❑2 TAR OR ASPHALT 7 VI P A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 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 7 GRAVITY _ A U 99 OTHER B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOABLE WALLED A U 7 LINED TRENCH U -- __ UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS STEH A U 71OLYVINYL CHLORIDE(PVC) A U A FIBERGLASSPIPf C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U I STEEL CLAD W/FRY A U 9 GALVANIZED STEEL A U 5 UNKNOWN A U A U B 100%METHANOL COMPATIBLE FHP 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY.OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. i P S IVISUAL CHECK P S 2 INVENTORY RECONCILIATION ♦ WELLS P S A ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 5 6 PRECISION TESTING P S X PRESSURE TESTING P S 91 NONE 3 P 5 95 UNKNOWN P 5 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE E7!7= - ESTIMATED DATE)AST USED IMO/YRI 2 ESTIMATEDGUANTIYYOF 1 WAS TANK FILLED WITH SUBSTANCE REMAINING W INERT MATERIAL' ❑YES Ej No -. _- GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT APPLIGANi'S NAME IPIIINT F'O A SIGNn I UTI(I DYI E!•. LOCAL AGENCY USE ONLY NTY# • COU--T JURISDICTION � AGENCY, ��_ l FACILITY TANK IO B 6 CURRENT AL AGENCY FACILITY ID• � - I APPROVED BY NAMa PHONE E WITH AREA CODE - PERMIT NUMBER & PERMIT APPROVAL DATE -- - - _ - -- PERMIT EXPIRATION GATE CHECK• pERwIT AMOUNT ---- SURCHARGE AMT. - ---- TEE CODE RECEIPT E By. FORM 8 E-Taal THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITEAPPLICATION, FORM 'A',UNLESS A CURRENT FORMA• HAS BEEN FILED I —.- ... _. DATA PROCESSING COPY :ATOSG:u17I,:'f:R.�' aR•an.:e.LAYPAIDlM19BEmrrcv:iuen3wn:x r... 'AI:.._..,,,.,y,yr,,,,,