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TANK IANWERMIT APPLICATION INFORM ON COMPLETE A SEPAWE FORM WITH THE FOLLOWING INFORMATI�OR EACH TANK. ".•� MARK ONLY ❑ I NEWPERMIT 3RENEWALPERMIT 5 5CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑^�4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: � FARM TANK-YES❑ NO _7 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 1 O A. OWNERS TANK ID N ® / B. MANUFACTURED BY: (L� I C. YEAR INSTALLED / nro I D. TANK CAPAGTY IN GALLONS: a,600 A 11. TANK ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,CqMPLETE ITEM D. f V A_ I MOTOR VEHICLE FUEL ❑2 PETROLEUMB. C UNLEADED ❑2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ A OIL �pRODUCT ❑N GASAHOL ❑5 JET NEL ❑ 6 AVIATION GAS N ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED A C.A.S.N CAS.N. XIII. TANK CONSTRUCTIQN MARK ONE ITEM ONLY IN BOX A,B,C,IL D A TYPE OF ❑ I BLL WALL F-13 SINGLE WALLED WITH EXTERIOR LINER E]95 UNKNOWN SYSTEM El SINGLE WALLED ❑1 SECONDARYCONTAINMENT [D 99 OTHER ❑ I STEEUIRON ❑2 STAINLESS STEEL F-13 FIBERCAASS ❑A STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR F-1I RUBBERUNED 2 ALKYD LINING ❑3 EPDXY LINING ❑I PHENOUCLINING LINING ❑ 5 GLASS LINING E] UNLINED 1 E] 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 00%METHANOL7 ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ I PaYETHLENEWRAP ❑2 TA ASPHALT F-13 VINYL WRAP ❑1 FIBERGLASS REINFORCED PLASTIC — PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NON ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE OUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A UTPR RE A U 3 GRAVITY A U 99 OTHER S. CONSTRUCTION A U I SINGLE WALLED A U 2 DOLL E WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINL 55 STEEL A U ] POLYVINYL CHLORIDE(PVC) A U A FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCR E A U 7 STEEL CLAD W/FRP A U B 10091 METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNO A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,4S FOR SECONDARY.A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P A 3 V DOSE WEDS P S C ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS P 5 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 91NNE P S 95 UNKNOWN P S W OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE LAST USED IMONA) 2 ESTIMATED QUANTIXY Of ].WAS TANK FILLED WITH SUBSTANCE REMAIN G IN GALLONS INERT MATERIAL'S ❑YES F] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, D TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PAINTED8 SIGNATURE Dl}Ei 9 � LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID N L 101 d / I ) 12) 1 yl loaQ CURRENT LOCAL AGENCY FACILITY ID N APPROVED SY NAME PHONE N WITH AREA CODE A PERMIT NUMBER PERM IT APPROVAL DATE I PERMIT EXPIRATION DATE CHECK• PERMIT AMOUNT SURCHARGE ANY. FEE CODE RECEIPTN BY: FORM A I3 7 BBI THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY _ -