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TANK (,,,--- TANNWERMIT APPLICATION INFORM ON , COMPLETE A SEP TE FORM WITH THE FOLLOWIN INFORMATI�OR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY C ONE ITEM ❑2 INTERIM PERMIT ❑ / AMENDED PERMIT 6 TEMPORARY TANK CLOSURE TANK REMO FACILITY/SITE NAME WHERE TANK IS INSTALLED: W FARM TANK-YES NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 9yZO 0 A. OWNERS TANK ID M .8 MANUFACTURED BY: .. /T C. YEAR INSTALLED U " D. TANK CAPACITY IN GALLONS. II. TANK CONTENTS IF( ),IS MARKED,COMPLETE ITEM C.IF(Al),IS NOT MARKED,COMPILE TE A N A. I MOTOR VEHICLE FUEL 2 PETROLEUM L1 C. Q 1 UNLEADED 2 DED ❑ 3 DIESEL N ❑ 3 CHEMICAL PRODUCT ❑ 1 OIL I PRODUCT ❑A GASAHOL JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ M EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑ 7 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.A. Kill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,6 D A TYPE OF ❑ BLE WALLED ❑3 SINGLE WALLED WITH EKTERIOR LINER ❑95 UNKNOWN SYSTEM 1 LE WALLED ❑ 1 SECONDARY CONTAINMENT ❑99 OTHER I STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑1 STEEL CUD WIFIBERGIASS REINFORCED PLASTIC ` B. TANK MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYL CHLORDE ❑ 7 ALUMINUM ❑8 10D%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZEDSTEEL ❑ 95 UNKNOWN ❑' 99 OTHER C. HITERIOR ❑ i RUBBER LINED ❑ 2 ALKYD LINING ❑3 EPOKYLININGF99 OUCUNING LINING ❑ 5 GLASS LINING ❑6 UNLINED I MOWN f_1ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL, ❑ YES [:] NOER D. CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT El >�NYL WRAP ❑1 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑ 99 OTHER W. PIPING INFORMA ION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND.BOTH IF APPLICABLE A SYSTEM TYPE A U 1 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 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U I FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A CONCRETE A U 7 STEEL CLAD W/FRP A U 8 I00%METHANOL COMPATIBLEFRP A U 9 GALVANIZED STEEL A U 5 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. �( 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S I ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELL$ 7 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I ESTIMATED DATE LAST USED(MO/YR) 2 ESTIMATED QUANTITY OF 3 WAS TANK EILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL' E:] YES [:] NO_ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MYKNOWLEDGE.IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED 6 SIGNATURF) DIT E, LOCAL AGENCY USE ONLY COUNTY A JURISDICTION M AGENCY P FACILITY ID M TANK 10 N CURRENT LOCAL AGENCY FACILITY ID• APPROVED BY NAME PHONE A WITH AREA CODE YA-MIk TJ I LPE R PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PEgMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT• BY: , t FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIED BY A FACIURY/SITE APPLICATION, FORM IA`,UNLESS A CURRENT FOR MAS BEEN FILED • _DATA PROCESSING COPY •