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TANK TANK PERMIT APPLICATION INFORMATION z, COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLYNEW PERMIT 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT 1 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 08 TANK REMOVED Q FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK•YES❑ NO -7 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 10 A. OWNERS TANK ID N B. MANUFACTURED BY: C.YEAR INSTALLED I D. TANK CAPACITY IN GALLONS: A II. TANK CONTENTS IF(ALT).IS MARKED,COMPLETE ITEM C.IF(ALT),IS NOT MARKED,COMPLETE ITEM 0, N A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ I UNLEADED ❑2 LEADED 3 DIESEL N ❑ 3 CHEMICAL PRODUCT 1 OK ❑ I PRODUCT ❑ GASAHl7L ❑5 JET FUEL ❑fi AVIATION GAS ❑ 5 HAZARDOUS ❑ 60 EMPTY ❑95 UNKNOWN ❑ 2 WASTE T METHANOL 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C A.S.N C.A.S.A. MI. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B.C,L D A TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED MTM EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLEWAUED ❑A SECONDARYCONTANMENT ❑99 OTHER ❑ I STEELIIRON ❑ 2 STAINLESS STEN ❑3 FIBERGLASS ❑A STEEL CUD WIFIBERGUSS REWORDED MASTIC 8.TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYL CHLORIDE 7 ALUMINUM ❑6 1 OD%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ ID GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ I RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑A PHENOLIC LINING G. INTERIOR F—] 5 GLASS LINING ❑6 UNLINED 1 ❑95 LMNOWN ❑ IS LINING MATERIAL COMPATIBE WITH 100%METHANOL' ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENEWRAP ❑ 2 TAROHASNWT ❑ 3VINYL WRAP ❑A F16ERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑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 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U %UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE LPVCI A U < FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U T STEEL CLAD W/FRP A U 8 HIX METHANOL COMPATISLEFRP A U 9 GALVANIZED STEEL 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. P S VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P S / ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S T PRESSURE TESTING P 5 91 NONE P S 95 UNKNOWN P 5 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I ESTIMATED DATE LAST USED(MOTYR) 2 ESTIMATED QUANTITY OF 3 WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL' ❑YES ❑ ND THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE, DA,E I, LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK IO N CURRENT LOCAL AGENCY FACILITY IO Y APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EKMR ION MATE CHECK• PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BV: FORM a(3 7-B8I THIS FORM MUST BE ACCOMPANIFO BY A FACILITY/SITE APPLICATION, FO R M W,UNLESS A CURRENT FORMA HAS BEEN FILED DATA PROCESSING COPY L