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I A14K IAIVF P01IM1T APPLICATION INFORMP TION COMPLETE A SEP TE FORM WITH THE FOLLOWING INFORMATI,,,rOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑J RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ONE ITEM ❑2 INTERIM PERMIT ❑ /AMENDED PERMIT ❑ I PERMANENTLY CLOSED TANK 6 TEMPORARY TANK CLOSURE F 634 K REMOVED 0 FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A OWNERS TANK IO N 1 B. MANUFACTURED BY: ,L� C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 13-5-0 II. TANK CONTENTS IF(At),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A A. ❑ I MOTOR VEHICLE FUEL ❑2 PET UM N ❑0 CHEMICAL PROpUCT B. B. C. ❑ I UNLEADED ❑2 LEADED 7 DIESEL N ❑5 HAZARDOUS ❑ ❑ ❑ I T ❑B GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS 00 EMPTY 95 UNKNOWN WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL ENTER NAME OF �/ � HAZARDOUS SUBSTANCE STORED 6 C A.S.N 'L-�+�e O C.A.S-N. (� x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B,C,L D A TYPE OF ❑ 1GaB�E WALLED J SINGLE WALLED NTH DaEROR LINER ❑951MKNOYM SYSTEM 1L''�T/SINGLE WALLED I SECONDARY CONTAINMENT 99 OTHER S.TANK STEEUNON ❑2 STAINLESS STEEL Cl J FIBERGLASS ❑1 STEEL CLAD W/RBERGUSSREBEgiCED RUSTIC 'I MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLOROF ❑ /ALUMINUM B 100%H,ETNANOL COMPAII&E FW ❑9 BRONZE 10 GALVANIZED SIBI ❑95 UNKNOWN 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED 2 ALKYD LINING ❑7 EPOKYLINING ❑/PHEy,�OLICLRENG LINING ❑ 5 GLASS UNING 6 UIIIMD 1 I US ""KNOWN ❑IS LINING MATERIAL COMPATIBLE NIH 100%METHAta, YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLTETILENE WRAP ❑Z TARg1A5RWT 0 VINYL WRAP 1 FIBERGLASS REINFORCED PLASTY: 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 %OTHER B.CONSTRUCTION IYSD SINGLE WALLED A U 2 DOUBLE WALLED A 9 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A STECUIRON A U 2 STAINLESS STEEL A U 9 POLYVINYL CHLORIDE INC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETF A U 7 STEEL CLAD W/FRP A U BIDBM METHANOL COMPATIBLE FHP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U "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 21NVENTOWRECONCILIATION • 5 WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING S 91 NONE P 5 95 UNKNOWN p 5 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1 ESTIMATED DATE LAST USED IMO/MRI - 2 ESTIMATED CIIANIIIY OF I WASIANKF.ILLEDWRH SIIDST AN<:F REMAINING IN INERT MATERIAL) ❑YES D NO� GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT APPLICANT'S NAME 1PRINI EO A SIGNA IURI I D/5 F�•. 1 I b LOCAL AGENCY USE ONLY COUNTY,T JURISDICTION B AGENCY F FACILITY IDB TANK ID N 201oz�D CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE•WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK N /ERMIT AMOUNT SURCHARGE AMT, FEE CODE RECEIR N '�'\FORM6477.801 THIS FORM MUST BE ACCOMPANIED BY A FACILITYTSITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HASBEENFILED \V `1110 DATA PROCESSING COPY rr